Global Experience in Building

Sustainable Healthy Communities

Overview from USA

Community Health and Wellbeing Through

Multi-Sectoral Partnerships

Blacktown NSW Australia

6 December 2011

John P Foreyt PhD

Baylor College of Medicine

Houston TX

jforeytbcmedu

Increasing prevalence of obesity

worldwide

Between 1980 amp 2008 the mean BMI

worldwide increased by 04 kgmsup2 per decade

for men and 05 kgmsup2 for women

In 2008 146 billion adults worldwide were

overweight or obese

Of these 205 million men (98) and 297

million women (138) were obese

Finucane et al Lancet 2011

Increasing prevalence of obesity in

USA

If the present trend is not halted it is projected

that by the year 2030 863 of adults in the

United States will be overweight or obese

Wang Beydoun Liang et al Obesity 2008

Sectors of Society

Arts amp Entertainment

Commerce amp Trade

Education

FamilyCommunity

Healthcare

Law amp Politics

Science amp Technology

Law and Politics

ldquoLetrsquos Moverdquo Campaign

In the end as First Lady

this isnrsquot just a policy issue

for me This is a passion

This is my mission I am

determined to work with

folks across this country to

change the way a

generation of kids thinks

about food and nutrition

Education

National School Lunch Program

Farmersrsquo Markets

Commerce and Trade

Science amp Technology

WiiFit

X-box

Kinect

Nike run

Health

Blogs

Phone Apps

Arts and Entertainment

Walking School

BusKids used to walk to school all the time Whatley says Now its almost impossible And with childhood obesity rates on the rise Whatley says walking is important because its the easiest way to exercise for a lifetime

FamilyCommunity

Health Care

Results of Lifestyle Interventions for

Weight Loss

ldquoThose who complete weight-loss programs lose approximately 10 of their body weight only to regain two-thirds of it back within one year and almost all of it back within 5 yearsrdquo

Institute of Medicine Weighing the options Criteria for evaluating

weight management programs 1995

Weekly group sessions over 4 ndash 6 months

Mean post-treatment weight reductions of ~ 8-10

Attrition rates are high at 2-yrs (mean = 39 range 20-65)

Attrition rates beyond 2-yrs (mean = 65)

Perri Foreyt amp Anton Preventing Weight

Regain After Weight Loss 2008

Results of Lifestyle Interventions for

Weight Loss

Results of Lifestyle Interventions

Pattern of Weight Regain

Weight regain occurs steadily over 2-5 yrs

Long-term follow-ups of behavioral interventions show a reliable pattern of gradual regaining of lost weight

Long-term losses of ge 5 Kg are sustained in less than 20 of patients in behavioral treatment

Perri Foreyt amp Anton Preventing Weight

Regain After Weight Loss 2008

Results of Lifestyle Interventions

Pattern of Weight Regain

ldquoThe difficulty associated with

maintaining lost weight appears to

be the result of physiological

environmental and psychological

factors that combine to facilitate a

regaining of lost weight and an

abandonment of weight control

effortsrdquo

Perri Foreyt amp Anton 2008

Population-wide prevention of obesity

Small changes in diet and physical activity may make more sense than focusing on large behavioral changes

By cutting 100 calories a day adults can prevent weight gain

Hill et al Science 2003 Hill AJCN 2009

BENEFITS OF MODEST WEIGHT LOSS

ldquoSeveral studies demonstrate that small losseshelliphelp reduce obesity-related co-morbidities and that improvements in these risk factors persist with maintenance of these modest weight lossesrdquo

Institute of Medicine 1995

- Glucose levels - HDL cholesterol levels

- Insulin levels - LDL cholesterol levels

- Glycated hemoglobin - Blood pressure

- Triglyceride levels - Quality of life levels

Stigmatization amp Discrimination

Societal beliefs that weight can be controlled thereby suggestive of character deficits (lack of willpower laziness and emotional problems)

Negative attitudes

ldquoLast safe prejudicerdquo in US society

Rand CSW Macgregor AMC South Med J 1990

DISCRIMINATION

THE PAIN OF OBESITY

Former severely obese patients

100 preferred to be deaf dyslexic

diabetic or have heart disease or bad

acne than to be obese again

Leg amputation was preferred by

915 and blindness by 894

100 preferred to be a normal weight

person rather than a severely obese

multi-millionaire Rand CSW Macgregor AMC Int J Obes 199115577ndash579

Psychosocial Burden of Obesity

Obese individuals often feel misunderstood neglected and rejected

Obese individuals have low employment prospects and are denied educational vocational and advancement opportunities

Significantly poorer quality of life

van Hout GCM van Oudheusden I amp van Heck GL Obes Surg 2004

A Healthy Lifestyle is All About

Balance

Healthy Diet

Healthy Physical Activity

Building Sustainable Healthy

Communities

Healthy Lifestyle

Building Sustainable Healthy

Communities

Healthy Lifestyle

UNFORTUNATELYhellip

Big Texan Steak Ranch

Amarillo Texas

72-oz Steak FREE if eaten within 1 hour

AVERAGE ADULT AMERICAN MAN

Height 5rsquo 8rdquo

Weight 195 lbs

Waist 397 in

BMI 284

CDC 2011

AVERAGE ADULT AMERICAN WOMAN

Height 5rsquo3rdquo

Weight 165 lbs

Waist 370 in

BMI 261

CDC 2011

Miss America

2008

Kirsten Haglund

BMI 1629

Eliana Ramos

Age 18

Height 5rsquo9rdquo

29th OLYMPIAD

BEIJING CHINA

US wrestling team captain Daniel

Cormier (2115 lbs) hospitalized for

kidney failure as result of

dehydration related to cutting weight

(did not compete)

US boxer Gary Russell was found

unconscious 4 days before his

Olympic bout due to cutting weight

(did not compete)

29th OLYMPIAD

BEIJING CHINA

Michael Phelps

8 Gold Medals SwimmingAge 23

Height 6rsquo4rdquo

Weight 195 lbs

BMI 2374

Daily Food Intake 10375 KCAL

(15 PRO 58 CHO 27 FAT)

Exercise 30 hrswk

2005 USDA FOOD PYRAMID

ldquoThe food pyramid

is too complicated

and has too many

messagesrdquo

Robert Post PhD USDA Deputy

Director 2011

2005 USDA FOOD PYRAMID

ldquoItrsquos going to be hard not to do

better than the current pyramid

which basically conveys no

useful informationrdquo

Walter C Willett MD

Chairman Department of Nutrition

Harvard School of Public Health

2011 USDA MY PLATE

ldquoWe are all

bombarded with so

many dietary

messages that it is

hard to find time to

sort through all this

informationrdquo

Michelle Obama 2011

Dietary Guidelines for Americans

2010 Two Primary Concepts

Maintain calorie balance over time to

achieve and maintain a healthy weight

Focus on consuming nutrient-dense foods

and beverages

Dietary Guidelines for Americans 2010

Efficacy-based comparative dietary guidelines

Carb Fat Pro

Mediterranean Diet 45-55 25-35 20

IOM Dietary Ref Intakes 45-65 25-35 15

NCEP-ATPIII 50-60 25-35 15

Am Dietetic Assoc 45-65 20-35 15

PARADOX OF INCREASING OBESITY

PREVALENCE

bull Focus on healthy eating and physical

activity

bull Awareness of dangers of obesity buthellip

bull Obesity prevalence continues to rise

bull Work amp commuting demands

bull Little time to exercise

bull Little time to prepare food

bull Availability of high-fatcalorie foods

Rationale for community-based interventions

bull Increases in obesity prevalence due to genes

bull Increased calories (eg 200 Kcalday

over 10 years)

bull Increased portion sizes (eg 22 oz

steaks and 44 oz sodas)

bull Western diets in developing nations

increase risk of obesity

READINESS TO CHANGE

ldquoHabit is habit and not to be

flung out of the window but

coaxed downstairs a step at a

timerdquo

Mark Twain

Long-Term Weight Maintenance

National Weight Control Registry (N=10000)

Survey of 3000 members who have been in the

Registry for at least 10 years

Starting weight = 224 lbs Average weight loss=69

lbs

At 5 years participants had maintained an average

weight loss=52 lbs

At 10 years participants had maintained an average

weight loss=51 lbs

Thomas Bond Phelan et al TOS 2011

Long-Term Weight Maintenance

Weight Maintainers report that they usually

Track their food intake

Count calories or fat grams

Follow a low-calorie low fat diet (1800 caloriesday

less than 30 of calories from fat

Eat breakfast regularly

Limit the amount they eat out (about 3 timesweek

eat fast food less than onceweek)

Thomas Bond Phelan et al TOS 2011

Long-Term Weight Maintenance

Weight Maintainers report that they usually

Eat similar food regularly

Donrsquot splurge much on holidays amp special occasions

Walk about one hourday

Watch less than 10 hours of TV a week

Weigh themselves at least once a week

Thomas Bond Phelan et al TOS 2011

LONG-TERM WEIGHT MAINTENANCE

Continued consumption of a low-

calorie diet with moderate fat intake

Limited fast food

High levels of physical activity

Phalen et al Obesity 2006 14 710-716

LONG-TERM WEIGHT MAINTENANCE

Daily weighing improved

maintenance of weight loss

particularly when delivered

face to face

Wing et al NEJM 2006 3551563-1571

Most Promising Strategies For

Preventing Weight Regain

Providing multi-component

programs with ongoing

professional contacts

Physical activityexercise

Portion controlmeal replacements

Extending treatment through

weekly or bi-weekly sessions

Pharmacotherapy

Perri Foreyt amp Anton Preventing Weight Regain After Weight Loss 2008

Most Promising Strategies For

Preventing Weight Regain

Extended treatments have shown

promise in promoting adherence to

the behaviors required for the long-

term maintenance of weight loss

Continuous care approach focused

on reasonable long-term objectives

appears appropriate for most

patients

Perri Foreyt amp Anton Preventing Weight Regain After Weight

Loss 2008

An Example of a successful long-term

intervention

The Look AHEAD Study

Does Weight Loss Reduce

Cardiovascular Disease and Death in

Overweight Individuals with Diabetes

bull Action for HEAlth in Diabetes

bull Objective to examine in overweight

persons with Type 2 Diabetes the long-

term effects of an intensive lifestyle

intervention program compared to

diabetes education and support

bull 16 Centers

bull 5145 overweight volunteers with

diabetes

Look AHEAD

Look AHEAD

Primary End Point Composite

bull Cardiovascular death (including fatal

myocardial infarction and stroke)

bull Non-fatal myocardial infarction

bull Non-fatal stroke

Winston-Salem

Baltimore

Philadelphia

New York

Providence

Boston

Clinical Site Coordinating Center

Clinical Sites

Seattle

Los Angeles

San AntonioHouston

Baton Rouge

Minneapolis

Memphis

Birmingham

Pittsburgh

Denver

Phoenix

Look AHEADParticipants

101100Baseline weight (kg)

589586Age (years)

9496Attended 1 year exam

360359Baseline BMI

1514Insulin Users

3737Minority

6059Women

(N=2574)(N=2630)

DSELifestyle

p lt 0004

Look AHEAD

Study Interventions

bull Diabetes support and education - DSE (control group)

bull Lifestyle intervention ndash ILI (treatment group)

Look AHEAD

Lifestyle Intervention

Goals

bull 7 weight loss for the group (10

for individual)

bull 175 minutes of moderate intensity

activity

Look AHEAD

Lifestyle Intervention

bull Diet

ndash ADA NCEP (lt 30 fat lt 10 sat fat

gt15 protein)

ndash 1200-1500 (if weight lt250lbs)

ndash 1500-1800 (if weight gt250lbs)

ndash During first 4 weeks to 4 months portion

control (liquid meal replacements or

structured meal plan)

Look AHEAD

Lifestyle Intervention

bull Physical Activity

ndash unsupervised

ndash 175 minutes moderate intensityweek

ndash 5 daysweek

ndash walking

Weight Loss at 1-Year

-9

ILI 0

-1

-2

-3

-4

-5

-6

-7

-8

DSE

p lt 00001

W

eig

ht

Chan

ge

86

07

The Look AHEAD Research Group Diabetes Care 2007

Reduction in Initial Weight by Gender

N=872

N=1229N=1197

N=830

-12

-10

-8

-6

-4

-2

0

0 2 4 6 8 10 12

Months

R

ed

uctio

n in

In

itia

l W

eig

ht

Men

Women

Plt0001

The Look AHEAD Research Group Diabetes Care 2007

Fitness Change () at 1-Year

0

5

10

15

20

25

Mean

Fitness C

hange

Unadjusted

Plt0001Adjusted for 1 Year

Weight Change Plt0001

58

209

108

159

DSE ILI ILIDSE

The Look AHEAD Research Group Diabetes Care 2007

1-Year Changes in Markers of

Diabetes Control

Markers of Diabetes

Control ILI DSE P-value

Hemoglobin A1c () BL

Hemoglobin A1c () Y1

Y1 ndash Baseline

725

661

-064

729

715

-014

026

lt0001

lt0001

Fasting glucose (mgdl) BL

Fasting glucose (mgdl) Y1

Y1 ndash Baseline

1519

1304

-215

1536

1464

-72

021

lt0001

lt0001

Diabetes medications BL

Diabetes medications Y1

Y1 ndash Baseline

865

786

-78

865

887

22

093

lt0001

lt0001

1-Year Changes in Markers of

Blood Pressure ControlMarkers of Blood Pressure

Control ILI DSE P-value

Systolic BP (mmHg) BL

Systolic BP (mmHg) Y1

Y1 ndash Baseline

1282

1214

-68

1294

1266

-28

026

lt0001

lt0001

Diastolic BP (mmHg) BL

Diastolic BP (mmHg) Y1

Y1 ndash Baseline

699

670

-30

704

686

-18

011

lt0001

lt0001

Antihypertensive medications BL

Antihypertensive medications Y1

Y1 ndash Baseline

753

752

-01

737

759

22

023

054

002

1-Year Changes in Markers of Lipid

Control

Markers of Lipid Control ILI DSE P-value

LDL-cholesterol (mgdl) BL

LDL-cholesterol (mgdl) Y1

Y1 ndash Baseline

1122

1070

-52

1124

1067

-57

078

074

049

HDL-cholesterol (mgdl) BL

HDL-cholesterol (mgdl) Y1

Y1 ndash Baseline

435

469

34

436

449

14

080

lt0001

lt0001

Triglycerides (mgdl) BL

Triglycerides (mgdl) Y1

Y1 ndash Baseline

1828

1525

-303

1800

1654

-146

038

lt0001

lt0001

Lipid lowering medications BL

Lipid lowering medications Y1

Y1 ndash Baseline

494

530

37

484

578

94

052

lt0001

lt0001

1-Year Changes in Percent of Participants

Meeting ADA Goals

ADA Goal ILI DSE P-value

Hemoglobin A1c lt 7 BL

Hemoglobin A1c lt 7 Y1

Y1 ndash Baseline

463

727

264

454

508

54

050

lt0001

lt0001

Blood pressure lt 13080 mmHg BL

Blood pressure lt 13080 mmHg Y1

Y1 ndash Baseline

535

686

151

499

570

70

001

lt0001

lt0001

LDL-cholesterol lt 100 mgdl BL

LDL-cholesterol lt 100 mgdl Y1

Y1 ndash Baseline

371

438

67

369

449

80

087

045

034

All three goals BL

All three goals Y1

Y1 ndash Baseline

108

236

128

95

160

65

013

lt0001

lt0001

Mean Changes in Weight Fitness amp BP

Averaged Over Four Years

DSE

Mean

ILI

Mean

P-value

Weight Loss

( initial wt)

-088 -615 lt 00001

Fitness

( METS)

196 1274 lt00001

HbA1c -009 -036 lt 00001

SBP (mm Hg) -297 -533 lt 00001

DBP (mm Hg) -248 -292 0012

Look AHEAD Research Group Arch Int Med 2010

Mean Changes in Lipid Profile

Averaged Over Four Years

DSE

Mean

ILI

Mean

P-value

HDL (mgdl) 197 367 lt00001

TG (mgdl) -1975 -2556 00006

LDL (mgdl) -1284 -1127 0009

LDL (mgdl)

(Adjusting for

medication use)

-922 -875 042

Look AHEAD Research Group Arch Int Med 2010

Percent () Completing Outcome

Measures at Years 1-4

Intervention Group

(ILI)

Year 1 971

Year 2 949

Year 3 940

Year 4 941

Comparison Group

(DSE)

Year 1 957

Year 2 935

Year 3 938

Year 4 931

Look AHEAD Summary

ILI had significantly greater improvements than DSE in all CVD risk factors averaged across 4 years (except LDL-C)

There may be long-term beneficial effects from this 4-year period in which ILI subjects have been exposed to lower CVD risk factors

Longer follow-ups will determine whether these lowered CVD risk factors can be maintained amp whether lifestyle intervention has positive effects on CVD morbidity amp mortality

Mary J

Female

White

56 years old at start of Look AHEAD

study

Past Medical History Type 2 diabetes

overweight diverticulosis arthritis

sleep apnea back pain

Mary J

bullLong term strugglesbull Helping youngest daughter with

personal issues and children

bull Rotator cuff problems

bull Degenerative disks in back

bull Rheumatoid arthritis

bull Diabetes

bull Physically demanding job

bull Financial struggles

Pounds

Years

82007 grandkids enter pre-school

Catherine L

Female

White

47 years old at start of Look AHEAD

study

Past Medical History Type 2 diabetes

overweight high blood pressure

hypothyroidism back pain

Catherine L

Long term struggles

bull Motherrsquos declining health and death

bull Multiple serious injuries

bull Sudden death of sister

bull Death of step-father

bull Declining economy

bull Children living at home

Pounds

Years

Realistic Management Goals

5-10 weight loss

Health energy and fitness

Well-being and self-esteem

Mood and appearance

Functional and recreational

activity

Key Elements

Focus on health and energy

Food and physical activity diaries

Gradual increase in physical activity

Gradual reduction in dietary fat

No feelings of food deprivation

Social support groups

Recommended Strategies for Building

Sustainable Healthy Communities

Overview from USA

Promote the availability of affordable healthy

food and beverages

Support healthy food and beverage choices

Encourage breastfeeding

Encourage physical activity or limit sedentary

activity among children amp youth

Create safe communities that support physical

activity

Encourage communities to organize for change

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Increase the availability of healthier food and

beverage choices in public service venues (eg

schools city amp county buildings etc)

--Insufficient evidence in school-based programs

--Associations suggest availability amp increased

consumption

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve availability of affordable healthier

food amp beverage choices in public service

venues

--Reducing the cost of healthier foods

increases their purchase

--Providing coupons redeemable for

healthier foods increases their purchase

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve geographic availability of

supermarkets in underserved areas

-- Greater access to nearby supermarkets is

associated with healthier eating behaviors

-- Increasing the number of supermarkets in

underserved neighborhoods increased

real estate values increased economic

activity amp employment amp resulted in lower

food prices

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Provide incentives to food retailers to locate in

andor offer healthier food choices in

underserved areas

-- Presence of retail venues that provide healthier

foods is associated with better nutrition

-- Greater availability of supermarkets was

associated with lower adolescent BMI scores

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Improve availability of mechanisms for

purchasing foods from farms

--Evidence supporting a direct link between

purchasing food from farms amp improved diet is

limited

--Two studies of initiatives to encourage

participation in farmersrsquo market showed

increased intention to eat more fruits amp

vegetables but no direct evidence

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Provide incentives for the production

distribution and procurement of foods from local

farms

--No evidence has been published to link local

food production amp health outcomes

--There is a current study exploring the potential

nutritional amp health benefits of eating locally

grown foods

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Restrict availability of less healthy foods amp

beverages in public service venues

--No peer-reviewed studies examined the impact

designed to restrict availability of less healthy

foods in public service venues

--21 states have policies that restrict the sale of

competitive foods in schools beyond USDA

regulations however no studies have evaluated

the impact of the policies

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Institute smaller portion size options in public

service venues

--Evidence is lacking to demonstrate effectiveness

of population-based interventions aimed at

reducing portion sizes in public service venues

--Evidence from clinical studies in laboratories

demonstrates decreasing portion sizes

decreases energy intake

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Limit advertisements of less healthy foods amp

beverages

--Little evidence is available regarding the impact

of restricting advertising on purchasing amp

consumption of less healthy foods

--Cross-sectional time-series studies of tobacco-

control efforts suggest an association between

advertising bans amp decreased tobacco

consumption

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Discourage consumption of sugar-sweetened

beverages

--One longitudinal study of a school-based

intervention among Native-American high school

students showed a substantial reduction in

sugar-sweetened beverages over a 3-year

period

--A RCT of a home-based intervention that

eliminated sugar-sweetened beverages showed

reduction in BMI scores

Recommended Community Strategies Strategies to encourage breastfeeding

Increase support for breastfeeding

--Evidence directly linking environmental

interventions that support breastfeeding with

obesity-related outcomes is lacking

--Epidemiologic studies indicate that breastfeeding

helps prevent pediatric obesity

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Require physical education in schools

--14 studies have demonstrated that school-based

PE was effective in increasing levels of physical

activity and improving physical fitness

--Minimum of 150 minwk in elementary schools

225 minwk in middle schools and high schools

throughout the school year as recommended by

NASPE

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Increase opportunities for extracurricular

physical activity

--Participation in after-school programs increased

studentsrsquo level of physical activity amp improved

obesity-related outcomes (improved CV fitness

reduced body fat)

--2 pilot studies providing extracurricular physical

activity showed increased levels of PA amp

decreased sedentary behavior

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Reduce screen time in public service venues

--A school-based RCT indicated that children who

reduced their television videotape amp video

game use had significant decrease in BMI tricep

skin fold thickness amp waist circumference

compared to controls

--Spending less time watching television is

associated with increased physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Improve access to outdoor recreational

facilities

--Review of 108 studies indicated that access to facilities

and programs for recreation near their homes amp time

spent outdoors correlated positively with increased

physical activity among childrenamp adults

--Perceptions that footpaths are safe for walking was

significantly associated with adults being classified as

physically active at a level sufficient for health benefits

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting

bicycling

--Longitudinal intervention studies have

demonstrated that improving bicycling

infrastructure is associated with increased

frequency of bicycling

--Cross-sectional studies indicated a significant

association between bicycling infrastructure amp

frequency of biking

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting walking

--Reviews of cross-sectional studies of

environmental correlates of physical activity amp

walking generally find a positive association

between infrastructure supportive of walking amp

physical activity

--Identifying amp creating safe routes to school

together with educational components

increased the number of students walking to

school

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Locating schools within easy walking

distance of residential areas

--Community-scale urban design amp land use policies amp

practices including locating schools stores workplaces

amp recreation areas close to residential areas are

effective in facilitating an increase in levels of physical

activity

--Majority of efforts to encourage walking to school involve

improving the routes rather than improving the location

of schools

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Improve access to public transportation

--Insufficient evidence exists to determine

effectiveness of transportation policies in

increasing the level of physical activity or

improving fitness

--1 study indicated that 29 of individuals who

walk to and from public transit achieve at least

30 minutes of daily physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Zone for mixed-use development

--Allows residential commercial institutional amp

other public land uses to be located in close

proximity to one another

--Studies using correlation analyses amp regression

models indicated that mixed land use was

associated with increased walking amp cycling

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance personal safety in areas where

persons are or could be physically active

--Cross-sectional studies have demonstrated a

negative relationship between crime rates andor

perceived safety amp physical activity in

neighborhoods

--Few intervention studies have evaluated the

impact of policies amp practices to improve

personal safety on physical activity

Geospatial Mapping Linking Urban

Environments to Health Risk

Measure association between environmental variables amp health risk factors

Assess relationships between variables at different levels of analysis

Used in conjunction with linear analyses

Our Community Environmental Model

of Obesity

Community Factors

Poverty

Crime

Grocery Quality

Restaurants

Parks

Sidewalks

Fast Food Outlets

Recreational

Facilities

Individual Factors

Dietary Intake

Physical Activity

Genetics

Family History

StressCoping

Eating Disorders

Psychological

Problems

Weight

Status

Chosen Neighborhoods

Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped

We then matched census-block groups within the income groups by population density and percentage of minority representation

One matched block group per income level was randomly selected

Prevalence of Obesity in

Block-Groups

0

5

10

15

20

25

30

35

40

45

50

Ag

e-a

dju

sted

Ob

esit

y P

rev

ale

nce

(

)

High-Income Low-Income

Age-standardized to the 1990 US Census

Density of Environmental Factors in the

Community Contributes to a ldquoToxicrdquo

Obesity Environment

0

2

4

6

8

10

12

14

16

18

Fast-food Convenience Store Bars

Den

sity

10

00

perso

ns

High-Income Low-Income

COMMUNITYrsquoS PERCEPTION OF SAFETY

0

5

10

15

20

25

30

35

40

Daytime Nighttime

Perc

en

t (

) F

eeli

ng

So

mew

hat

Safe

or

Un

safe

Low-Income High-Income

Percent Substandard (or worse) Housing

or Ground Conditions

of Residential Properties

0

10

20

30

Structural Grounds

Perc

en

t (

)

Low-Income High-Income

CONCLUSIONS

These data suggest that the higher

frequency of outlets providing

calorically-dense foods and alcohol may

contribute to greater obesity prevalence

in residents of low-income communities

More research is needed to thoroughly

document environmental determinants

of health and obesity

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

From 1994-1998 HUD randomly assigned

4498 women with children living in public

housing in high-poverty urban census

tracts to one of three groups (1) housing

vouchers redeemable only if they moved

to a low-poverty census tract (2)

unrestricted vouchers or (3) control group

(no vouchers)

Ludwig et al NEJM 201136516

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

10-12 year follow-up showed modest but

potentially important reductions in the

prevalence of extreme obesity amp diabetes in the

group moving from a neighborhood with high

poverty on one of low poverty compared to the

control group

No differences between the group receiving

traditional vouchers amp the control group

ldquoNeighborhoods matterrdquo

Ludwig et al NEJM 201136516

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance traffic safety in areas where

persons are or could be physically active

--Community-scale urban design amp land use policies to

promote physical activity including design components

to improve street lighting infrastructure projects to

increase safety of pedestrian street crossing and use of

traffic calming approaches such as speed humps amp

traffic circles are effective in increasing physical activity

--Both community-scale amp street-scale policies amp practices

are effective in increasing physical activity

Recommended Community Strategies Encourage Communities to Organize for Change

Participate in community coalitions or

partnerships to address obesity

--Little evidence is available to determine the

impact of community coalitions on obesity

prevention

--The presence of anti-smoking community

coalitions has been associated with lower rates

of tobacco consumption

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

$103 million awarded to 61 states and

communities including state amp local government

agencies tribes amp territories amp state amp local non-

profit organizations

To build capacity to implement changes for

community prevention efforts to ensure long-

term success

To implement evidence-based and practice-

based programs to improve health amp wellness

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Priority areas are

Tobacco-free living

Active living and healthy eating

Evidence-based quality clinical and other

preventive health services for prevention

and control of high blood pressure and

high cholesterol

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Applicants proposed specific activities in

line with their chosen priority areas in their

applications

Grantee activities will not be finalized until

plans are negotiated with CDC by early

2012

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Capacity-Building Award

The Confederated Tribes of The Chehalis

Reservation is receiving a $498663 planning

award to build capacity to support healthy

lifestyles among their tribal population of 1500

in Washington State

Work will target tobacco-free living active living

and healthy eating and quality clinical and other

healthy serviceswwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Implementation Award

Austin TX Dept of Health and Human Services

is receiving $1026158 to serve Travis County

(Austin) to expand efforts in tobacco-free living

active living and healthy eating quality clinical

and other preventive services social and

emotional wellness and healthy and safe

physical environmentswwwcdcgov1052011

Building sustainable healthy

communities Bottom line

Obesity is an environmental problem

Despite progress in genetic research public health advances only will occur when we take the environment seriously

Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment

Until we do this we will not make substantial progress in addressing the epidemic of obesity

Poston amp Foreyt Atherosclerosis 1999

Whatrsquos the best approach

Integrate all sectors of society into community

change interventions

Incorporate

Science amp Technology

Education

FamilyCommunity

Healthcare

Arts amp Entertainment

Law amp Politics

Commerce amp Trade

Sectors of Society

Arts amp Entertainm

ent

Commerce amp Trade

Education

FamilyCommunity

Healthcare

Law amp Politics

Science amp Technology

Project FIT rationale design and baseline characteristics of a school- and community-

based intervention to address physical activity and healthy eating among low-income

elementary school children

Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D

Oh HJ Orth J Randall S Mayfield K Holmes D

Source

Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu

Abstract

BACKGROUND

This paper describes Project FIT a collaboration between the public school system local

health systems physicians neighborhood associations businesses faith-based leaders

community agencies and university researchers to develop a multi-faceted approach to

promote physical activity and healthy eating toward the general goal of preventing and

reducing childhood obesity among children in Grand Rapids MI USA

METHODSDESIGN

There are four overall components to Project FIT school community social marketing and

school staff wellness - all that focus on 1) increasing access to safe and affordable physical

activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)

improving the affordability and availability of nutritious food in the neighborhoods surrounding

the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding

nutrition and physical activity among school staff parents and students 4) impacting the

culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging

dialogue among all community partners to leverage existing programs and introduce new

ones

Increasing prevalence of obesity

worldwide

Between 1980 amp 2008 the mean BMI

worldwide increased by 04 kgmsup2 per decade

for men and 05 kgmsup2 for women

In 2008 146 billion adults worldwide were

overweight or obese

Of these 205 million men (98) and 297

million women (138) were obese

Finucane et al Lancet 2011

Increasing prevalence of obesity in

USA

If the present trend is not halted it is projected

that by the year 2030 863 of adults in the

United States will be overweight or obese

Wang Beydoun Liang et al Obesity 2008

Sectors of Society

Arts amp Entertainment

Commerce amp Trade

Education

FamilyCommunity

Healthcare

Law amp Politics

Science amp Technology

Law and Politics

ldquoLetrsquos Moverdquo Campaign

In the end as First Lady

this isnrsquot just a policy issue

for me This is a passion

This is my mission I am

determined to work with

folks across this country to

change the way a

generation of kids thinks

about food and nutrition

Education

National School Lunch Program

Farmersrsquo Markets

Commerce and Trade

Science amp Technology

WiiFit

X-box

Kinect

Nike run

Health

Blogs

Phone Apps

Arts and Entertainment

Walking School

BusKids used to walk to school all the time Whatley says Now its almost impossible And with childhood obesity rates on the rise Whatley says walking is important because its the easiest way to exercise for a lifetime

FamilyCommunity

Health Care

Results of Lifestyle Interventions for

Weight Loss

ldquoThose who complete weight-loss programs lose approximately 10 of their body weight only to regain two-thirds of it back within one year and almost all of it back within 5 yearsrdquo

Institute of Medicine Weighing the options Criteria for evaluating

weight management programs 1995

Weekly group sessions over 4 ndash 6 months

Mean post-treatment weight reductions of ~ 8-10

Attrition rates are high at 2-yrs (mean = 39 range 20-65)

Attrition rates beyond 2-yrs (mean = 65)

Perri Foreyt amp Anton Preventing Weight

Regain After Weight Loss 2008

Results of Lifestyle Interventions for

Weight Loss

Results of Lifestyle Interventions

Pattern of Weight Regain

Weight regain occurs steadily over 2-5 yrs

Long-term follow-ups of behavioral interventions show a reliable pattern of gradual regaining of lost weight

Long-term losses of ge 5 Kg are sustained in less than 20 of patients in behavioral treatment

Perri Foreyt amp Anton Preventing Weight

Regain After Weight Loss 2008

Results of Lifestyle Interventions

Pattern of Weight Regain

ldquoThe difficulty associated with

maintaining lost weight appears to

be the result of physiological

environmental and psychological

factors that combine to facilitate a

regaining of lost weight and an

abandonment of weight control

effortsrdquo

Perri Foreyt amp Anton 2008

Population-wide prevention of obesity

Small changes in diet and physical activity may make more sense than focusing on large behavioral changes

By cutting 100 calories a day adults can prevent weight gain

Hill et al Science 2003 Hill AJCN 2009

BENEFITS OF MODEST WEIGHT LOSS

ldquoSeveral studies demonstrate that small losseshelliphelp reduce obesity-related co-morbidities and that improvements in these risk factors persist with maintenance of these modest weight lossesrdquo

Institute of Medicine 1995

- Glucose levels - HDL cholesterol levels

- Insulin levels - LDL cholesterol levels

- Glycated hemoglobin - Blood pressure

- Triglyceride levels - Quality of life levels

Stigmatization amp Discrimination

Societal beliefs that weight can be controlled thereby suggestive of character deficits (lack of willpower laziness and emotional problems)

Negative attitudes

ldquoLast safe prejudicerdquo in US society

Rand CSW Macgregor AMC South Med J 1990

DISCRIMINATION

THE PAIN OF OBESITY

Former severely obese patients

100 preferred to be deaf dyslexic

diabetic or have heart disease or bad

acne than to be obese again

Leg amputation was preferred by

915 and blindness by 894

100 preferred to be a normal weight

person rather than a severely obese

multi-millionaire Rand CSW Macgregor AMC Int J Obes 199115577ndash579

Psychosocial Burden of Obesity

Obese individuals often feel misunderstood neglected and rejected

Obese individuals have low employment prospects and are denied educational vocational and advancement opportunities

Significantly poorer quality of life

van Hout GCM van Oudheusden I amp van Heck GL Obes Surg 2004

A Healthy Lifestyle is All About

Balance

Healthy Diet

Healthy Physical Activity

Building Sustainable Healthy

Communities

Healthy Lifestyle

Building Sustainable Healthy

Communities

Healthy Lifestyle

UNFORTUNATELYhellip

Big Texan Steak Ranch

Amarillo Texas

72-oz Steak FREE if eaten within 1 hour

AVERAGE ADULT AMERICAN MAN

Height 5rsquo 8rdquo

Weight 195 lbs

Waist 397 in

BMI 284

CDC 2011

AVERAGE ADULT AMERICAN WOMAN

Height 5rsquo3rdquo

Weight 165 lbs

Waist 370 in

BMI 261

CDC 2011

Miss America

2008

Kirsten Haglund

BMI 1629

Eliana Ramos

Age 18

Height 5rsquo9rdquo

29th OLYMPIAD

BEIJING CHINA

US wrestling team captain Daniel

Cormier (2115 lbs) hospitalized for

kidney failure as result of

dehydration related to cutting weight

(did not compete)

US boxer Gary Russell was found

unconscious 4 days before his

Olympic bout due to cutting weight

(did not compete)

29th OLYMPIAD

BEIJING CHINA

Michael Phelps

8 Gold Medals SwimmingAge 23

Height 6rsquo4rdquo

Weight 195 lbs

BMI 2374

Daily Food Intake 10375 KCAL

(15 PRO 58 CHO 27 FAT)

Exercise 30 hrswk

2005 USDA FOOD PYRAMID

ldquoThe food pyramid

is too complicated

and has too many

messagesrdquo

Robert Post PhD USDA Deputy

Director 2011

2005 USDA FOOD PYRAMID

ldquoItrsquos going to be hard not to do

better than the current pyramid

which basically conveys no

useful informationrdquo

Walter C Willett MD

Chairman Department of Nutrition

Harvard School of Public Health

2011 USDA MY PLATE

ldquoWe are all

bombarded with so

many dietary

messages that it is

hard to find time to

sort through all this

informationrdquo

Michelle Obama 2011

Dietary Guidelines for Americans

2010 Two Primary Concepts

Maintain calorie balance over time to

achieve and maintain a healthy weight

Focus on consuming nutrient-dense foods

and beverages

Dietary Guidelines for Americans 2010

Efficacy-based comparative dietary guidelines

Carb Fat Pro

Mediterranean Diet 45-55 25-35 20

IOM Dietary Ref Intakes 45-65 25-35 15

NCEP-ATPIII 50-60 25-35 15

Am Dietetic Assoc 45-65 20-35 15

PARADOX OF INCREASING OBESITY

PREVALENCE

bull Focus on healthy eating and physical

activity

bull Awareness of dangers of obesity buthellip

bull Obesity prevalence continues to rise

bull Work amp commuting demands

bull Little time to exercise

bull Little time to prepare food

bull Availability of high-fatcalorie foods

Rationale for community-based interventions

bull Increases in obesity prevalence due to genes

bull Increased calories (eg 200 Kcalday

over 10 years)

bull Increased portion sizes (eg 22 oz

steaks and 44 oz sodas)

bull Western diets in developing nations

increase risk of obesity

READINESS TO CHANGE

ldquoHabit is habit and not to be

flung out of the window but

coaxed downstairs a step at a

timerdquo

Mark Twain

Long-Term Weight Maintenance

National Weight Control Registry (N=10000)

Survey of 3000 members who have been in the

Registry for at least 10 years

Starting weight = 224 lbs Average weight loss=69

lbs

At 5 years participants had maintained an average

weight loss=52 lbs

At 10 years participants had maintained an average

weight loss=51 lbs

Thomas Bond Phelan et al TOS 2011

Long-Term Weight Maintenance

Weight Maintainers report that they usually

Track their food intake

Count calories or fat grams

Follow a low-calorie low fat diet (1800 caloriesday

less than 30 of calories from fat

Eat breakfast regularly

Limit the amount they eat out (about 3 timesweek

eat fast food less than onceweek)

Thomas Bond Phelan et al TOS 2011

Long-Term Weight Maintenance

Weight Maintainers report that they usually

Eat similar food regularly

Donrsquot splurge much on holidays amp special occasions

Walk about one hourday

Watch less than 10 hours of TV a week

Weigh themselves at least once a week

Thomas Bond Phelan et al TOS 2011

LONG-TERM WEIGHT MAINTENANCE

Continued consumption of a low-

calorie diet with moderate fat intake

Limited fast food

High levels of physical activity

Phalen et al Obesity 2006 14 710-716

LONG-TERM WEIGHT MAINTENANCE

Daily weighing improved

maintenance of weight loss

particularly when delivered

face to face

Wing et al NEJM 2006 3551563-1571

Most Promising Strategies For

Preventing Weight Regain

Providing multi-component

programs with ongoing

professional contacts

Physical activityexercise

Portion controlmeal replacements

Extending treatment through

weekly or bi-weekly sessions

Pharmacotherapy

Perri Foreyt amp Anton Preventing Weight Regain After Weight Loss 2008

Most Promising Strategies For

Preventing Weight Regain

Extended treatments have shown

promise in promoting adherence to

the behaviors required for the long-

term maintenance of weight loss

Continuous care approach focused

on reasonable long-term objectives

appears appropriate for most

patients

Perri Foreyt amp Anton Preventing Weight Regain After Weight

Loss 2008

An Example of a successful long-term

intervention

The Look AHEAD Study

Does Weight Loss Reduce

Cardiovascular Disease and Death in

Overweight Individuals with Diabetes

bull Action for HEAlth in Diabetes

bull Objective to examine in overweight

persons with Type 2 Diabetes the long-

term effects of an intensive lifestyle

intervention program compared to

diabetes education and support

bull 16 Centers

bull 5145 overweight volunteers with

diabetes

Look AHEAD

Look AHEAD

Primary End Point Composite

bull Cardiovascular death (including fatal

myocardial infarction and stroke)

bull Non-fatal myocardial infarction

bull Non-fatal stroke

Winston-Salem

Baltimore

Philadelphia

New York

Providence

Boston

Clinical Site Coordinating Center

Clinical Sites

Seattle

Los Angeles

San AntonioHouston

Baton Rouge

Minneapolis

Memphis

Birmingham

Pittsburgh

Denver

Phoenix

Look AHEADParticipants

101100Baseline weight (kg)

589586Age (years)

9496Attended 1 year exam

360359Baseline BMI

1514Insulin Users

3737Minority

6059Women

(N=2574)(N=2630)

DSELifestyle

p lt 0004

Look AHEAD

Study Interventions

bull Diabetes support and education - DSE (control group)

bull Lifestyle intervention ndash ILI (treatment group)

Look AHEAD

Lifestyle Intervention

Goals

bull 7 weight loss for the group (10

for individual)

bull 175 minutes of moderate intensity

activity

Look AHEAD

Lifestyle Intervention

bull Diet

ndash ADA NCEP (lt 30 fat lt 10 sat fat

gt15 protein)

ndash 1200-1500 (if weight lt250lbs)

ndash 1500-1800 (if weight gt250lbs)

ndash During first 4 weeks to 4 months portion

control (liquid meal replacements or

structured meal plan)

Look AHEAD

Lifestyle Intervention

bull Physical Activity

ndash unsupervised

ndash 175 minutes moderate intensityweek

ndash 5 daysweek

ndash walking

Weight Loss at 1-Year

-9

ILI 0

-1

-2

-3

-4

-5

-6

-7

-8

DSE

p lt 00001

W

eig

ht

Chan

ge

86

07

The Look AHEAD Research Group Diabetes Care 2007

Reduction in Initial Weight by Gender

N=872

N=1229N=1197

N=830

-12

-10

-8

-6

-4

-2

0

0 2 4 6 8 10 12

Months

R

ed

uctio

n in

In

itia

l W

eig

ht

Men

Women

Plt0001

The Look AHEAD Research Group Diabetes Care 2007

Fitness Change () at 1-Year

0

5

10

15

20

25

Mean

Fitness C

hange

Unadjusted

Plt0001Adjusted for 1 Year

Weight Change Plt0001

58

209

108

159

DSE ILI ILIDSE

The Look AHEAD Research Group Diabetes Care 2007

1-Year Changes in Markers of

Diabetes Control

Markers of Diabetes

Control ILI DSE P-value

Hemoglobin A1c () BL

Hemoglobin A1c () Y1

Y1 ndash Baseline

725

661

-064

729

715

-014

026

lt0001

lt0001

Fasting glucose (mgdl) BL

Fasting glucose (mgdl) Y1

Y1 ndash Baseline

1519

1304

-215

1536

1464

-72

021

lt0001

lt0001

Diabetes medications BL

Diabetes medications Y1

Y1 ndash Baseline

865

786

-78

865

887

22

093

lt0001

lt0001

1-Year Changes in Markers of

Blood Pressure ControlMarkers of Blood Pressure

Control ILI DSE P-value

Systolic BP (mmHg) BL

Systolic BP (mmHg) Y1

Y1 ndash Baseline

1282

1214

-68

1294

1266

-28

026

lt0001

lt0001

Diastolic BP (mmHg) BL

Diastolic BP (mmHg) Y1

Y1 ndash Baseline

699

670

-30

704

686

-18

011

lt0001

lt0001

Antihypertensive medications BL

Antihypertensive medications Y1

Y1 ndash Baseline

753

752

-01

737

759

22

023

054

002

1-Year Changes in Markers of Lipid

Control

Markers of Lipid Control ILI DSE P-value

LDL-cholesterol (mgdl) BL

LDL-cholesterol (mgdl) Y1

Y1 ndash Baseline

1122

1070

-52

1124

1067

-57

078

074

049

HDL-cholesterol (mgdl) BL

HDL-cholesterol (mgdl) Y1

Y1 ndash Baseline

435

469

34

436

449

14

080

lt0001

lt0001

Triglycerides (mgdl) BL

Triglycerides (mgdl) Y1

Y1 ndash Baseline

1828

1525

-303

1800

1654

-146

038

lt0001

lt0001

Lipid lowering medications BL

Lipid lowering medications Y1

Y1 ndash Baseline

494

530

37

484

578

94

052

lt0001

lt0001

1-Year Changes in Percent of Participants

Meeting ADA Goals

ADA Goal ILI DSE P-value

Hemoglobin A1c lt 7 BL

Hemoglobin A1c lt 7 Y1

Y1 ndash Baseline

463

727

264

454

508

54

050

lt0001

lt0001

Blood pressure lt 13080 mmHg BL

Blood pressure lt 13080 mmHg Y1

Y1 ndash Baseline

535

686

151

499

570

70

001

lt0001

lt0001

LDL-cholesterol lt 100 mgdl BL

LDL-cholesterol lt 100 mgdl Y1

Y1 ndash Baseline

371

438

67

369

449

80

087

045

034

All three goals BL

All three goals Y1

Y1 ndash Baseline

108

236

128

95

160

65

013

lt0001

lt0001

Mean Changes in Weight Fitness amp BP

Averaged Over Four Years

DSE

Mean

ILI

Mean

P-value

Weight Loss

( initial wt)

-088 -615 lt 00001

Fitness

( METS)

196 1274 lt00001

HbA1c -009 -036 lt 00001

SBP (mm Hg) -297 -533 lt 00001

DBP (mm Hg) -248 -292 0012

Look AHEAD Research Group Arch Int Med 2010

Mean Changes in Lipid Profile

Averaged Over Four Years

DSE

Mean

ILI

Mean

P-value

HDL (mgdl) 197 367 lt00001

TG (mgdl) -1975 -2556 00006

LDL (mgdl) -1284 -1127 0009

LDL (mgdl)

(Adjusting for

medication use)

-922 -875 042

Look AHEAD Research Group Arch Int Med 2010

Percent () Completing Outcome

Measures at Years 1-4

Intervention Group

(ILI)

Year 1 971

Year 2 949

Year 3 940

Year 4 941

Comparison Group

(DSE)

Year 1 957

Year 2 935

Year 3 938

Year 4 931

Look AHEAD Summary

ILI had significantly greater improvements than DSE in all CVD risk factors averaged across 4 years (except LDL-C)

There may be long-term beneficial effects from this 4-year period in which ILI subjects have been exposed to lower CVD risk factors

Longer follow-ups will determine whether these lowered CVD risk factors can be maintained amp whether lifestyle intervention has positive effects on CVD morbidity amp mortality

Mary J

Female

White

56 years old at start of Look AHEAD

study

Past Medical History Type 2 diabetes

overweight diverticulosis arthritis

sleep apnea back pain

Mary J

bullLong term strugglesbull Helping youngest daughter with

personal issues and children

bull Rotator cuff problems

bull Degenerative disks in back

bull Rheumatoid arthritis

bull Diabetes

bull Physically demanding job

bull Financial struggles

Pounds

Years

82007 grandkids enter pre-school

Catherine L

Female

White

47 years old at start of Look AHEAD

study

Past Medical History Type 2 diabetes

overweight high blood pressure

hypothyroidism back pain

Catherine L

Long term struggles

bull Motherrsquos declining health and death

bull Multiple serious injuries

bull Sudden death of sister

bull Death of step-father

bull Declining economy

bull Children living at home

Pounds

Years

Realistic Management Goals

5-10 weight loss

Health energy and fitness

Well-being and self-esteem

Mood and appearance

Functional and recreational

activity

Key Elements

Focus on health and energy

Food and physical activity diaries

Gradual increase in physical activity

Gradual reduction in dietary fat

No feelings of food deprivation

Social support groups

Recommended Strategies for Building

Sustainable Healthy Communities

Overview from USA

Promote the availability of affordable healthy

food and beverages

Support healthy food and beverage choices

Encourage breastfeeding

Encourage physical activity or limit sedentary

activity among children amp youth

Create safe communities that support physical

activity

Encourage communities to organize for change

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Increase the availability of healthier food and

beverage choices in public service venues (eg

schools city amp county buildings etc)

--Insufficient evidence in school-based programs

--Associations suggest availability amp increased

consumption

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve availability of affordable healthier

food amp beverage choices in public service

venues

--Reducing the cost of healthier foods

increases their purchase

--Providing coupons redeemable for

healthier foods increases their purchase

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve geographic availability of

supermarkets in underserved areas

-- Greater access to nearby supermarkets is

associated with healthier eating behaviors

-- Increasing the number of supermarkets in

underserved neighborhoods increased

real estate values increased economic

activity amp employment amp resulted in lower

food prices

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Provide incentives to food retailers to locate in

andor offer healthier food choices in

underserved areas

-- Presence of retail venues that provide healthier

foods is associated with better nutrition

-- Greater availability of supermarkets was

associated with lower adolescent BMI scores

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Improve availability of mechanisms for

purchasing foods from farms

--Evidence supporting a direct link between

purchasing food from farms amp improved diet is

limited

--Two studies of initiatives to encourage

participation in farmersrsquo market showed

increased intention to eat more fruits amp

vegetables but no direct evidence

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Provide incentives for the production

distribution and procurement of foods from local

farms

--No evidence has been published to link local

food production amp health outcomes

--There is a current study exploring the potential

nutritional amp health benefits of eating locally

grown foods

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Restrict availability of less healthy foods amp

beverages in public service venues

--No peer-reviewed studies examined the impact

designed to restrict availability of less healthy

foods in public service venues

--21 states have policies that restrict the sale of

competitive foods in schools beyond USDA

regulations however no studies have evaluated

the impact of the policies

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Institute smaller portion size options in public

service venues

--Evidence is lacking to demonstrate effectiveness

of population-based interventions aimed at

reducing portion sizes in public service venues

--Evidence from clinical studies in laboratories

demonstrates decreasing portion sizes

decreases energy intake

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Limit advertisements of less healthy foods amp

beverages

--Little evidence is available regarding the impact

of restricting advertising on purchasing amp

consumption of less healthy foods

--Cross-sectional time-series studies of tobacco-

control efforts suggest an association between

advertising bans amp decreased tobacco

consumption

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Discourage consumption of sugar-sweetened

beverages

--One longitudinal study of a school-based

intervention among Native-American high school

students showed a substantial reduction in

sugar-sweetened beverages over a 3-year

period

--A RCT of a home-based intervention that

eliminated sugar-sweetened beverages showed

reduction in BMI scores

Recommended Community Strategies Strategies to encourage breastfeeding

Increase support for breastfeeding

--Evidence directly linking environmental

interventions that support breastfeeding with

obesity-related outcomes is lacking

--Epidemiologic studies indicate that breastfeeding

helps prevent pediatric obesity

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Require physical education in schools

--14 studies have demonstrated that school-based

PE was effective in increasing levels of physical

activity and improving physical fitness

--Minimum of 150 minwk in elementary schools

225 minwk in middle schools and high schools

throughout the school year as recommended by

NASPE

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Increase opportunities for extracurricular

physical activity

--Participation in after-school programs increased

studentsrsquo level of physical activity amp improved

obesity-related outcomes (improved CV fitness

reduced body fat)

--2 pilot studies providing extracurricular physical

activity showed increased levels of PA amp

decreased sedentary behavior

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Reduce screen time in public service venues

--A school-based RCT indicated that children who

reduced their television videotape amp video

game use had significant decrease in BMI tricep

skin fold thickness amp waist circumference

compared to controls

--Spending less time watching television is

associated with increased physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Improve access to outdoor recreational

facilities

--Review of 108 studies indicated that access to facilities

and programs for recreation near their homes amp time

spent outdoors correlated positively with increased

physical activity among childrenamp adults

--Perceptions that footpaths are safe for walking was

significantly associated with adults being classified as

physically active at a level sufficient for health benefits

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting

bicycling

--Longitudinal intervention studies have

demonstrated that improving bicycling

infrastructure is associated with increased

frequency of bicycling

--Cross-sectional studies indicated a significant

association between bicycling infrastructure amp

frequency of biking

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting walking

--Reviews of cross-sectional studies of

environmental correlates of physical activity amp

walking generally find a positive association

between infrastructure supportive of walking amp

physical activity

--Identifying amp creating safe routes to school

together with educational components

increased the number of students walking to

school

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Locating schools within easy walking

distance of residential areas

--Community-scale urban design amp land use policies amp

practices including locating schools stores workplaces

amp recreation areas close to residential areas are

effective in facilitating an increase in levels of physical

activity

--Majority of efforts to encourage walking to school involve

improving the routes rather than improving the location

of schools

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Improve access to public transportation

--Insufficient evidence exists to determine

effectiveness of transportation policies in

increasing the level of physical activity or

improving fitness

--1 study indicated that 29 of individuals who

walk to and from public transit achieve at least

30 minutes of daily physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Zone for mixed-use development

--Allows residential commercial institutional amp

other public land uses to be located in close

proximity to one another

--Studies using correlation analyses amp regression

models indicated that mixed land use was

associated with increased walking amp cycling

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance personal safety in areas where

persons are or could be physically active

--Cross-sectional studies have demonstrated a

negative relationship between crime rates andor

perceived safety amp physical activity in

neighborhoods

--Few intervention studies have evaluated the

impact of policies amp practices to improve

personal safety on physical activity

Geospatial Mapping Linking Urban

Environments to Health Risk

Measure association between environmental variables amp health risk factors

Assess relationships between variables at different levels of analysis

Used in conjunction with linear analyses

Our Community Environmental Model

of Obesity

Community Factors

Poverty

Crime

Grocery Quality

Restaurants

Parks

Sidewalks

Fast Food Outlets

Recreational

Facilities

Individual Factors

Dietary Intake

Physical Activity

Genetics

Family History

StressCoping

Eating Disorders

Psychological

Problems

Weight

Status

Chosen Neighborhoods

Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped

We then matched census-block groups within the income groups by population density and percentage of minority representation

One matched block group per income level was randomly selected

Prevalence of Obesity in

Block-Groups

0

5

10

15

20

25

30

35

40

45

50

Ag

e-a

dju

sted

Ob

esit

y P

rev

ale

nce

(

)

High-Income Low-Income

Age-standardized to the 1990 US Census

Density of Environmental Factors in the

Community Contributes to a ldquoToxicrdquo

Obesity Environment

0

2

4

6

8

10

12

14

16

18

Fast-food Convenience Store Bars

Den

sity

10

00

perso

ns

High-Income Low-Income

COMMUNITYrsquoS PERCEPTION OF SAFETY

0

5

10

15

20

25

30

35

40

Daytime Nighttime

Perc

en

t (

) F

eeli

ng

So

mew

hat

Safe

or

Un

safe

Low-Income High-Income

Percent Substandard (or worse) Housing

or Ground Conditions

of Residential Properties

0

10

20

30

Structural Grounds

Perc

en

t (

)

Low-Income High-Income

CONCLUSIONS

These data suggest that the higher

frequency of outlets providing

calorically-dense foods and alcohol may

contribute to greater obesity prevalence

in residents of low-income communities

More research is needed to thoroughly

document environmental determinants

of health and obesity

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

From 1994-1998 HUD randomly assigned

4498 women with children living in public

housing in high-poverty urban census

tracts to one of three groups (1) housing

vouchers redeemable only if they moved

to a low-poverty census tract (2)

unrestricted vouchers or (3) control group

(no vouchers)

Ludwig et al NEJM 201136516

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

10-12 year follow-up showed modest but

potentially important reductions in the

prevalence of extreme obesity amp diabetes in the

group moving from a neighborhood with high

poverty on one of low poverty compared to the

control group

No differences between the group receiving

traditional vouchers amp the control group

ldquoNeighborhoods matterrdquo

Ludwig et al NEJM 201136516

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance traffic safety in areas where

persons are or could be physically active

--Community-scale urban design amp land use policies to

promote physical activity including design components

to improve street lighting infrastructure projects to

increase safety of pedestrian street crossing and use of

traffic calming approaches such as speed humps amp

traffic circles are effective in increasing physical activity

--Both community-scale amp street-scale policies amp practices

are effective in increasing physical activity

Recommended Community Strategies Encourage Communities to Organize for Change

Participate in community coalitions or

partnerships to address obesity

--Little evidence is available to determine the

impact of community coalitions on obesity

prevention

--The presence of anti-smoking community

coalitions has been associated with lower rates

of tobacco consumption

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

$103 million awarded to 61 states and

communities including state amp local government

agencies tribes amp territories amp state amp local non-

profit organizations

To build capacity to implement changes for

community prevention efforts to ensure long-

term success

To implement evidence-based and practice-

based programs to improve health amp wellness

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Priority areas are

Tobacco-free living

Active living and healthy eating

Evidence-based quality clinical and other

preventive health services for prevention

and control of high blood pressure and

high cholesterol

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Applicants proposed specific activities in

line with their chosen priority areas in their

applications

Grantee activities will not be finalized until

plans are negotiated with CDC by early

2012

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Capacity-Building Award

The Confederated Tribes of The Chehalis

Reservation is receiving a $498663 planning

award to build capacity to support healthy

lifestyles among their tribal population of 1500

in Washington State

Work will target tobacco-free living active living

and healthy eating and quality clinical and other

healthy serviceswwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Implementation Award

Austin TX Dept of Health and Human Services

is receiving $1026158 to serve Travis County

(Austin) to expand efforts in tobacco-free living

active living and healthy eating quality clinical

and other preventive services social and

emotional wellness and healthy and safe

physical environmentswwwcdcgov1052011

Building sustainable healthy

communities Bottom line

Obesity is an environmental problem

Despite progress in genetic research public health advances only will occur when we take the environment seriously

Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment

Until we do this we will not make substantial progress in addressing the epidemic of obesity

Poston amp Foreyt Atherosclerosis 1999

Whatrsquos the best approach

Integrate all sectors of society into community

change interventions

Incorporate

Science amp Technology

Education

FamilyCommunity

Healthcare

Arts amp Entertainment

Law amp Politics

Commerce amp Trade

Sectors of Society

Arts amp Entertainm

ent

Commerce amp Trade

Education

FamilyCommunity

Healthcare

Law amp Politics

Science amp Technology

Project FIT rationale design and baseline characteristics of a school- and community-

based intervention to address physical activity and healthy eating among low-income

elementary school children

Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D

Oh HJ Orth J Randall S Mayfield K Holmes D

Source

Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu

Abstract

BACKGROUND

This paper describes Project FIT a collaboration between the public school system local

health systems physicians neighborhood associations businesses faith-based leaders

community agencies and university researchers to develop a multi-faceted approach to

promote physical activity and healthy eating toward the general goal of preventing and

reducing childhood obesity among children in Grand Rapids MI USA

METHODSDESIGN

There are four overall components to Project FIT school community social marketing and

school staff wellness - all that focus on 1) increasing access to safe and affordable physical

activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)

improving the affordability and availability of nutritious food in the neighborhoods surrounding

the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding

nutrition and physical activity among school staff parents and students 4) impacting the

culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging

dialogue among all community partners to leverage existing programs and introduce new

ones

Increasing prevalence of obesity in

USA

If the present trend is not halted it is projected

that by the year 2030 863 of adults in the

United States will be overweight or obese

Wang Beydoun Liang et al Obesity 2008

Sectors of Society

Arts amp Entertainment

Commerce amp Trade

Education

FamilyCommunity

Healthcare

Law amp Politics

Science amp Technology

Law and Politics

ldquoLetrsquos Moverdquo Campaign

In the end as First Lady

this isnrsquot just a policy issue

for me This is a passion

This is my mission I am

determined to work with

folks across this country to

change the way a

generation of kids thinks

about food and nutrition

Education

National School Lunch Program

Farmersrsquo Markets

Commerce and Trade

Science amp Technology

WiiFit

X-box

Kinect

Nike run

Health

Blogs

Phone Apps

Arts and Entertainment

Walking School

BusKids used to walk to school all the time Whatley says Now its almost impossible And with childhood obesity rates on the rise Whatley says walking is important because its the easiest way to exercise for a lifetime

FamilyCommunity

Health Care

Results of Lifestyle Interventions for

Weight Loss

ldquoThose who complete weight-loss programs lose approximately 10 of their body weight only to regain two-thirds of it back within one year and almost all of it back within 5 yearsrdquo

Institute of Medicine Weighing the options Criteria for evaluating

weight management programs 1995

Weekly group sessions over 4 ndash 6 months

Mean post-treatment weight reductions of ~ 8-10

Attrition rates are high at 2-yrs (mean = 39 range 20-65)

Attrition rates beyond 2-yrs (mean = 65)

Perri Foreyt amp Anton Preventing Weight

Regain After Weight Loss 2008

Results of Lifestyle Interventions for

Weight Loss

Results of Lifestyle Interventions

Pattern of Weight Regain

Weight regain occurs steadily over 2-5 yrs

Long-term follow-ups of behavioral interventions show a reliable pattern of gradual regaining of lost weight

Long-term losses of ge 5 Kg are sustained in less than 20 of patients in behavioral treatment

Perri Foreyt amp Anton Preventing Weight

Regain After Weight Loss 2008

Results of Lifestyle Interventions

Pattern of Weight Regain

ldquoThe difficulty associated with

maintaining lost weight appears to

be the result of physiological

environmental and psychological

factors that combine to facilitate a

regaining of lost weight and an

abandonment of weight control

effortsrdquo

Perri Foreyt amp Anton 2008

Population-wide prevention of obesity

Small changes in diet and physical activity may make more sense than focusing on large behavioral changes

By cutting 100 calories a day adults can prevent weight gain

Hill et al Science 2003 Hill AJCN 2009

BENEFITS OF MODEST WEIGHT LOSS

ldquoSeveral studies demonstrate that small losseshelliphelp reduce obesity-related co-morbidities and that improvements in these risk factors persist with maintenance of these modest weight lossesrdquo

Institute of Medicine 1995

- Glucose levels - HDL cholesterol levels

- Insulin levels - LDL cholesterol levels

- Glycated hemoglobin - Blood pressure

- Triglyceride levels - Quality of life levels

Stigmatization amp Discrimination

Societal beliefs that weight can be controlled thereby suggestive of character deficits (lack of willpower laziness and emotional problems)

Negative attitudes

ldquoLast safe prejudicerdquo in US society

Rand CSW Macgregor AMC South Med J 1990

DISCRIMINATION

THE PAIN OF OBESITY

Former severely obese patients

100 preferred to be deaf dyslexic

diabetic or have heart disease or bad

acne than to be obese again

Leg amputation was preferred by

915 and blindness by 894

100 preferred to be a normal weight

person rather than a severely obese

multi-millionaire Rand CSW Macgregor AMC Int J Obes 199115577ndash579

Psychosocial Burden of Obesity

Obese individuals often feel misunderstood neglected and rejected

Obese individuals have low employment prospects and are denied educational vocational and advancement opportunities

Significantly poorer quality of life

van Hout GCM van Oudheusden I amp van Heck GL Obes Surg 2004

A Healthy Lifestyle is All About

Balance

Healthy Diet

Healthy Physical Activity

Building Sustainable Healthy

Communities

Healthy Lifestyle

Building Sustainable Healthy

Communities

Healthy Lifestyle

UNFORTUNATELYhellip

Big Texan Steak Ranch

Amarillo Texas

72-oz Steak FREE if eaten within 1 hour

AVERAGE ADULT AMERICAN MAN

Height 5rsquo 8rdquo

Weight 195 lbs

Waist 397 in

BMI 284

CDC 2011

AVERAGE ADULT AMERICAN WOMAN

Height 5rsquo3rdquo

Weight 165 lbs

Waist 370 in

BMI 261

CDC 2011

Miss America

2008

Kirsten Haglund

BMI 1629

Eliana Ramos

Age 18

Height 5rsquo9rdquo

29th OLYMPIAD

BEIJING CHINA

US wrestling team captain Daniel

Cormier (2115 lbs) hospitalized for

kidney failure as result of

dehydration related to cutting weight

(did not compete)

US boxer Gary Russell was found

unconscious 4 days before his

Olympic bout due to cutting weight

(did not compete)

29th OLYMPIAD

BEIJING CHINA

Michael Phelps

8 Gold Medals SwimmingAge 23

Height 6rsquo4rdquo

Weight 195 lbs

BMI 2374

Daily Food Intake 10375 KCAL

(15 PRO 58 CHO 27 FAT)

Exercise 30 hrswk

2005 USDA FOOD PYRAMID

ldquoThe food pyramid

is too complicated

and has too many

messagesrdquo

Robert Post PhD USDA Deputy

Director 2011

2005 USDA FOOD PYRAMID

ldquoItrsquos going to be hard not to do

better than the current pyramid

which basically conveys no

useful informationrdquo

Walter C Willett MD

Chairman Department of Nutrition

Harvard School of Public Health

2011 USDA MY PLATE

ldquoWe are all

bombarded with so

many dietary

messages that it is

hard to find time to

sort through all this

informationrdquo

Michelle Obama 2011

Dietary Guidelines for Americans

2010 Two Primary Concepts

Maintain calorie balance over time to

achieve and maintain a healthy weight

Focus on consuming nutrient-dense foods

and beverages

Dietary Guidelines for Americans 2010

Efficacy-based comparative dietary guidelines

Carb Fat Pro

Mediterranean Diet 45-55 25-35 20

IOM Dietary Ref Intakes 45-65 25-35 15

NCEP-ATPIII 50-60 25-35 15

Am Dietetic Assoc 45-65 20-35 15

PARADOX OF INCREASING OBESITY

PREVALENCE

bull Focus on healthy eating and physical

activity

bull Awareness of dangers of obesity buthellip

bull Obesity prevalence continues to rise

bull Work amp commuting demands

bull Little time to exercise

bull Little time to prepare food

bull Availability of high-fatcalorie foods

Rationale for community-based interventions

bull Increases in obesity prevalence due to genes

bull Increased calories (eg 200 Kcalday

over 10 years)

bull Increased portion sizes (eg 22 oz

steaks and 44 oz sodas)

bull Western diets in developing nations

increase risk of obesity

READINESS TO CHANGE

ldquoHabit is habit and not to be

flung out of the window but

coaxed downstairs a step at a

timerdquo

Mark Twain

Long-Term Weight Maintenance

National Weight Control Registry (N=10000)

Survey of 3000 members who have been in the

Registry for at least 10 years

Starting weight = 224 lbs Average weight loss=69

lbs

At 5 years participants had maintained an average

weight loss=52 lbs

At 10 years participants had maintained an average

weight loss=51 lbs

Thomas Bond Phelan et al TOS 2011

Long-Term Weight Maintenance

Weight Maintainers report that they usually

Track their food intake

Count calories or fat grams

Follow a low-calorie low fat diet (1800 caloriesday

less than 30 of calories from fat

Eat breakfast regularly

Limit the amount they eat out (about 3 timesweek

eat fast food less than onceweek)

Thomas Bond Phelan et al TOS 2011

Long-Term Weight Maintenance

Weight Maintainers report that they usually

Eat similar food regularly

Donrsquot splurge much on holidays amp special occasions

Walk about one hourday

Watch less than 10 hours of TV a week

Weigh themselves at least once a week

Thomas Bond Phelan et al TOS 2011

LONG-TERM WEIGHT MAINTENANCE

Continued consumption of a low-

calorie diet with moderate fat intake

Limited fast food

High levels of physical activity

Phalen et al Obesity 2006 14 710-716

LONG-TERM WEIGHT MAINTENANCE

Daily weighing improved

maintenance of weight loss

particularly when delivered

face to face

Wing et al NEJM 2006 3551563-1571

Most Promising Strategies For

Preventing Weight Regain

Providing multi-component

programs with ongoing

professional contacts

Physical activityexercise

Portion controlmeal replacements

Extending treatment through

weekly or bi-weekly sessions

Pharmacotherapy

Perri Foreyt amp Anton Preventing Weight Regain After Weight Loss 2008

Most Promising Strategies For

Preventing Weight Regain

Extended treatments have shown

promise in promoting adherence to

the behaviors required for the long-

term maintenance of weight loss

Continuous care approach focused

on reasonable long-term objectives

appears appropriate for most

patients

Perri Foreyt amp Anton Preventing Weight Regain After Weight

Loss 2008

An Example of a successful long-term

intervention

The Look AHEAD Study

Does Weight Loss Reduce

Cardiovascular Disease and Death in

Overweight Individuals with Diabetes

bull Action for HEAlth in Diabetes

bull Objective to examine in overweight

persons with Type 2 Diabetes the long-

term effects of an intensive lifestyle

intervention program compared to

diabetes education and support

bull 16 Centers

bull 5145 overweight volunteers with

diabetes

Look AHEAD

Look AHEAD

Primary End Point Composite

bull Cardiovascular death (including fatal

myocardial infarction and stroke)

bull Non-fatal myocardial infarction

bull Non-fatal stroke

Winston-Salem

Baltimore

Philadelphia

New York

Providence

Boston

Clinical Site Coordinating Center

Clinical Sites

Seattle

Los Angeles

San AntonioHouston

Baton Rouge

Minneapolis

Memphis

Birmingham

Pittsburgh

Denver

Phoenix

Look AHEADParticipants

101100Baseline weight (kg)

589586Age (years)

9496Attended 1 year exam

360359Baseline BMI

1514Insulin Users

3737Minority

6059Women

(N=2574)(N=2630)

DSELifestyle

p lt 0004

Look AHEAD

Study Interventions

bull Diabetes support and education - DSE (control group)

bull Lifestyle intervention ndash ILI (treatment group)

Look AHEAD

Lifestyle Intervention

Goals

bull 7 weight loss for the group (10

for individual)

bull 175 minutes of moderate intensity

activity

Look AHEAD

Lifestyle Intervention

bull Diet

ndash ADA NCEP (lt 30 fat lt 10 sat fat

gt15 protein)

ndash 1200-1500 (if weight lt250lbs)

ndash 1500-1800 (if weight gt250lbs)

ndash During first 4 weeks to 4 months portion

control (liquid meal replacements or

structured meal plan)

Look AHEAD

Lifestyle Intervention

bull Physical Activity

ndash unsupervised

ndash 175 minutes moderate intensityweek

ndash 5 daysweek

ndash walking

Weight Loss at 1-Year

-9

ILI 0

-1

-2

-3

-4

-5

-6

-7

-8

DSE

p lt 00001

W

eig

ht

Chan

ge

86

07

The Look AHEAD Research Group Diabetes Care 2007

Reduction in Initial Weight by Gender

N=872

N=1229N=1197

N=830

-12

-10

-8

-6

-4

-2

0

0 2 4 6 8 10 12

Months

R

ed

uctio

n in

In

itia

l W

eig

ht

Men

Women

Plt0001

The Look AHEAD Research Group Diabetes Care 2007

Fitness Change () at 1-Year

0

5

10

15

20

25

Mean

Fitness C

hange

Unadjusted

Plt0001Adjusted for 1 Year

Weight Change Plt0001

58

209

108

159

DSE ILI ILIDSE

The Look AHEAD Research Group Diabetes Care 2007

1-Year Changes in Markers of

Diabetes Control

Markers of Diabetes

Control ILI DSE P-value

Hemoglobin A1c () BL

Hemoglobin A1c () Y1

Y1 ndash Baseline

725

661

-064

729

715

-014

026

lt0001

lt0001

Fasting glucose (mgdl) BL

Fasting glucose (mgdl) Y1

Y1 ndash Baseline

1519

1304

-215

1536

1464

-72

021

lt0001

lt0001

Diabetes medications BL

Diabetes medications Y1

Y1 ndash Baseline

865

786

-78

865

887

22

093

lt0001

lt0001

1-Year Changes in Markers of

Blood Pressure ControlMarkers of Blood Pressure

Control ILI DSE P-value

Systolic BP (mmHg) BL

Systolic BP (mmHg) Y1

Y1 ndash Baseline

1282

1214

-68

1294

1266

-28

026

lt0001

lt0001

Diastolic BP (mmHg) BL

Diastolic BP (mmHg) Y1

Y1 ndash Baseline

699

670

-30

704

686

-18

011

lt0001

lt0001

Antihypertensive medications BL

Antihypertensive medications Y1

Y1 ndash Baseline

753

752

-01

737

759

22

023

054

002

1-Year Changes in Markers of Lipid

Control

Markers of Lipid Control ILI DSE P-value

LDL-cholesterol (mgdl) BL

LDL-cholesterol (mgdl) Y1

Y1 ndash Baseline

1122

1070

-52

1124

1067

-57

078

074

049

HDL-cholesterol (mgdl) BL

HDL-cholesterol (mgdl) Y1

Y1 ndash Baseline

435

469

34

436

449

14

080

lt0001

lt0001

Triglycerides (mgdl) BL

Triglycerides (mgdl) Y1

Y1 ndash Baseline

1828

1525

-303

1800

1654

-146

038

lt0001

lt0001

Lipid lowering medications BL

Lipid lowering medications Y1

Y1 ndash Baseline

494

530

37

484

578

94

052

lt0001

lt0001

1-Year Changes in Percent of Participants

Meeting ADA Goals

ADA Goal ILI DSE P-value

Hemoglobin A1c lt 7 BL

Hemoglobin A1c lt 7 Y1

Y1 ndash Baseline

463

727

264

454

508

54

050

lt0001

lt0001

Blood pressure lt 13080 mmHg BL

Blood pressure lt 13080 mmHg Y1

Y1 ndash Baseline

535

686

151

499

570

70

001

lt0001

lt0001

LDL-cholesterol lt 100 mgdl BL

LDL-cholesterol lt 100 mgdl Y1

Y1 ndash Baseline

371

438

67

369

449

80

087

045

034

All three goals BL

All three goals Y1

Y1 ndash Baseline

108

236

128

95

160

65

013

lt0001

lt0001

Mean Changes in Weight Fitness amp BP

Averaged Over Four Years

DSE

Mean

ILI

Mean

P-value

Weight Loss

( initial wt)

-088 -615 lt 00001

Fitness

( METS)

196 1274 lt00001

HbA1c -009 -036 lt 00001

SBP (mm Hg) -297 -533 lt 00001

DBP (mm Hg) -248 -292 0012

Look AHEAD Research Group Arch Int Med 2010

Mean Changes in Lipid Profile

Averaged Over Four Years

DSE

Mean

ILI

Mean

P-value

HDL (mgdl) 197 367 lt00001

TG (mgdl) -1975 -2556 00006

LDL (mgdl) -1284 -1127 0009

LDL (mgdl)

(Adjusting for

medication use)

-922 -875 042

Look AHEAD Research Group Arch Int Med 2010

Percent () Completing Outcome

Measures at Years 1-4

Intervention Group

(ILI)

Year 1 971

Year 2 949

Year 3 940

Year 4 941

Comparison Group

(DSE)

Year 1 957

Year 2 935

Year 3 938

Year 4 931

Look AHEAD Summary

ILI had significantly greater improvements than DSE in all CVD risk factors averaged across 4 years (except LDL-C)

There may be long-term beneficial effects from this 4-year period in which ILI subjects have been exposed to lower CVD risk factors

Longer follow-ups will determine whether these lowered CVD risk factors can be maintained amp whether lifestyle intervention has positive effects on CVD morbidity amp mortality

Mary J

Female

White

56 years old at start of Look AHEAD

study

Past Medical History Type 2 diabetes

overweight diverticulosis arthritis

sleep apnea back pain

Mary J

bullLong term strugglesbull Helping youngest daughter with

personal issues and children

bull Rotator cuff problems

bull Degenerative disks in back

bull Rheumatoid arthritis

bull Diabetes

bull Physically demanding job

bull Financial struggles

Pounds

Years

82007 grandkids enter pre-school

Catherine L

Female

White

47 years old at start of Look AHEAD

study

Past Medical History Type 2 diabetes

overweight high blood pressure

hypothyroidism back pain

Catherine L

Long term struggles

bull Motherrsquos declining health and death

bull Multiple serious injuries

bull Sudden death of sister

bull Death of step-father

bull Declining economy

bull Children living at home

Pounds

Years

Realistic Management Goals

5-10 weight loss

Health energy and fitness

Well-being and self-esteem

Mood and appearance

Functional and recreational

activity

Key Elements

Focus on health and energy

Food and physical activity diaries

Gradual increase in physical activity

Gradual reduction in dietary fat

No feelings of food deprivation

Social support groups

Recommended Strategies for Building

Sustainable Healthy Communities

Overview from USA

Promote the availability of affordable healthy

food and beverages

Support healthy food and beverage choices

Encourage breastfeeding

Encourage physical activity or limit sedentary

activity among children amp youth

Create safe communities that support physical

activity

Encourage communities to organize for change

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Increase the availability of healthier food and

beverage choices in public service venues (eg

schools city amp county buildings etc)

--Insufficient evidence in school-based programs

--Associations suggest availability amp increased

consumption

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve availability of affordable healthier

food amp beverage choices in public service

venues

--Reducing the cost of healthier foods

increases their purchase

--Providing coupons redeemable for

healthier foods increases their purchase

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve geographic availability of

supermarkets in underserved areas

-- Greater access to nearby supermarkets is

associated with healthier eating behaviors

-- Increasing the number of supermarkets in

underserved neighborhoods increased

real estate values increased economic

activity amp employment amp resulted in lower

food prices

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Provide incentives to food retailers to locate in

andor offer healthier food choices in

underserved areas

-- Presence of retail venues that provide healthier

foods is associated with better nutrition

-- Greater availability of supermarkets was

associated with lower adolescent BMI scores

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Improve availability of mechanisms for

purchasing foods from farms

--Evidence supporting a direct link between

purchasing food from farms amp improved diet is

limited

--Two studies of initiatives to encourage

participation in farmersrsquo market showed

increased intention to eat more fruits amp

vegetables but no direct evidence

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Provide incentives for the production

distribution and procurement of foods from local

farms

--No evidence has been published to link local

food production amp health outcomes

--There is a current study exploring the potential

nutritional amp health benefits of eating locally

grown foods

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Restrict availability of less healthy foods amp

beverages in public service venues

--No peer-reviewed studies examined the impact

designed to restrict availability of less healthy

foods in public service venues

--21 states have policies that restrict the sale of

competitive foods in schools beyond USDA

regulations however no studies have evaluated

the impact of the policies

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Institute smaller portion size options in public

service venues

--Evidence is lacking to demonstrate effectiveness

of population-based interventions aimed at

reducing portion sizes in public service venues

--Evidence from clinical studies in laboratories

demonstrates decreasing portion sizes

decreases energy intake

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Limit advertisements of less healthy foods amp

beverages

--Little evidence is available regarding the impact

of restricting advertising on purchasing amp

consumption of less healthy foods

--Cross-sectional time-series studies of tobacco-

control efforts suggest an association between

advertising bans amp decreased tobacco

consumption

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Discourage consumption of sugar-sweetened

beverages

--One longitudinal study of a school-based

intervention among Native-American high school

students showed a substantial reduction in

sugar-sweetened beverages over a 3-year

period

--A RCT of a home-based intervention that

eliminated sugar-sweetened beverages showed

reduction in BMI scores

Recommended Community Strategies Strategies to encourage breastfeeding

Increase support for breastfeeding

--Evidence directly linking environmental

interventions that support breastfeeding with

obesity-related outcomes is lacking

--Epidemiologic studies indicate that breastfeeding

helps prevent pediatric obesity

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Require physical education in schools

--14 studies have demonstrated that school-based

PE was effective in increasing levels of physical

activity and improving physical fitness

--Minimum of 150 minwk in elementary schools

225 minwk in middle schools and high schools

throughout the school year as recommended by

NASPE

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Increase opportunities for extracurricular

physical activity

--Participation in after-school programs increased

studentsrsquo level of physical activity amp improved

obesity-related outcomes (improved CV fitness

reduced body fat)

--2 pilot studies providing extracurricular physical

activity showed increased levels of PA amp

decreased sedentary behavior

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Reduce screen time in public service venues

--A school-based RCT indicated that children who

reduced their television videotape amp video

game use had significant decrease in BMI tricep

skin fold thickness amp waist circumference

compared to controls

--Spending less time watching television is

associated with increased physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Improve access to outdoor recreational

facilities

--Review of 108 studies indicated that access to facilities

and programs for recreation near their homes amp time

spent outdoors correlated positively with increased

physical activity among childrenamp adults

--Perceptions that footpaths are safe for walking was

significantly associated with adults being classified as

physically active at a level sufficient for health benefits

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting

bicycling

--Longitudinal intervention studies have

demonstrated that improving bicycling

infrastructure is associated with increased

frequency of bicycling

--Cross-sectional studies indicated a significant

association between bicycling infrastructure amp

frequency of biking

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting walking

--Reviews of cross-sectional studies of

environmental correlates of physical activity amp

walking generally find a positive association

between infrastructure supportive of walking amp

physical activity

--Identifying amp creating safe routes to school

together with educational components

increased the number of students walking to

school

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Locating schools within easy walking

distance of residential areas

--Community-scale urban design amp land use policies amp

practices including locating schools stores workplaces

amp recreation areas close to residential areas are

effective in facilitating an increase in levels of physical

activity

--Majority of efforts to encourage walking to school involve

improving the routes rather than improving the location

of schools

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Improve access to public transportation

--Insufficient evidence exists to determine

effectiveness of transportation policies in

increasing the level of physical activity or

improving fitness

--1 study indicated that 29 of individuals who

walk to and from public transit achieve at least

30 minutes of daily physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Zone for mixed-use development

--Allows residential commercial institutional amp

other public land uses to be located in close

proximity to one another

--Studies using correlation analyses amp regression

models indicated that mixed land use was

associated with increased walking amp cycling

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance personal safety in areas where

persons are or could be physically active

--Cross-sectional studies have demonstrated a

negative relationship between crime rates andor

perceived safety amp physical activity in

neighborhoods

--Few intervention studies have evaluated the

impact of policies amp practices to improve

personal safety on physical activity

Geospatial Mapping Linking Urban

Environments to Health Risk

Measure association between environmental variables amp health risk factors

Assess relationships between variables at different levels of analysis

Used in conjunction with linear analyses

Our Community Environmental Model

of Obesity

Community Factors

Poverty

Crime

Grocery Quality

Restaurants

Parks

Sidewalks

Fast Food Outlets

Recreational

Facilities

Individual Factors

Dietary Intake

Physical Activity

Genetics

Family History

StressCoping

Eating Disorders

Psychological

Problems

Weight

Status

Chosen Neighborhoods

Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped

We then matched census-block groups within the income groups by population density and percentage of minority representation

One matched block group per income level was randomly selected

Prevalence of Obesity in

Block-Groups

0

5

10

15

20

25

30

35

40

45

50

Ag

e-a

dju

sted

Ob

esit

y P

rev

ale

nce

(

)

High-Income Low-Income

Age-standardized to the 1990 US Census

Density of Environmental Factors in the

Community Contributes to a ldquoToxicrdquo

Obesity Environment

0

2

4

6

8

10

12

14

16

18

Fast-food Convenience Store Bars

Den

sity

10

00

perso

ns

High-Income Low-Income

COMMUNITYrsquoS PERCEPTION OF SAFETY

0

5

10

15

20

25

30

35

40

Daytime Nighttime

Perc

en

t (

) F

eeli

ng

So

mew

hat

Safe

or

Un

safe

Low-Income High-Income

Percent Substandard (or worse) Housing

or Ground Conditions

of Residential Properties

0

10

20

30

Structural Grounds

Perc

en

t (

)

Low-Income High-Income

CONCLUSIONS

These data suggest that the higher

frequency of outlets providing

calorically-dense foods and alcohol may

contribute to greater obesity prevalence

in residents of low-income communities

More research is needed to thoroughly

document environmental determinants

of health and obesity

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

From 1994-1998 HUD randomly assigned

4498 women with children living in public

housing in high-poverty urban census

tracts to one of three groups (1) housing

vouchers redeemable only if they moved

to a low-poverty census tract (2)

unrestricted vouchers or (3) control group

(no vouchers)

Ludwig et al NEJM 201136516

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

10-12 year follow-up showed modest but

potentially important reductions in the

prevalence of extreme obesity amp diabetes in the

group moving from a neighborhood with high

poverty on one of low poverty compared to the

control group

No differences between the group receiving

traditional vouchers amp the control group

ldquoNeighborhoods matterrdquo

Ludwig et al NEJM 201136516

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance traffic safety in areas where

persons are or could be physically active

--Community-scale urban design amp land use policies to

promote physical activity including design components

to improve street lighting infrastructure projects to

increase safety of pedestrian street crossing and use of

traffic calming approaches such as speed humps amp

traffic circles are effective in increasing physical activity

--Both community-scale amp street-scale policies amp practices

are effective in increasing physical activity

Recommended Community Strategies Encourage Communities to Organize for Change

Participate in community coalitions or

partnerships to address obesity

--Little evidence is available to determine the

impact of community coalitions on obesity

prevention

--The presence of anti-smoking community

coalitions has been associated with lower rates

of tobacco consumption

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

$103 million awarded to 61 states and

communities including state amp local government

agencies tribes amp territories amp state amp local non-

profit organizations

To build capacity to implement changes for

community prevention efforts to ensure long-

term success

To implement evidence-based and practice-

based programs to improve health amp wellness

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Priority areas are

Tobacco-free living

Active living and healthy eating

Evidence-based quality clinical and other

preventive health services for prevention

and control of high blood pressure and

high cholesterol

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Applicants proposed specific activities in

line with their chosen priority areas in their

applications

Grantee activities will not be finalized until

plans are negotiated with CDC by early

2012

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Capacity-Building Award

The Confederated Tribes of The Chehalis

Reservation is receiving a $498663 planning

award to build capacity to support healthy

lifestyles among their tribal population of 1500

in Washington State

Work will target tobacco-free living active living

and healthy eating and quality clinical and other

healthy serviceswwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Implementation Award

Austin TX Dept of Health and Human Services

is receiving $1026158 to serve Travis County

(Austin) to expand efforts in tobacco-free living

active living and healthy eating quality clinical

and other preventive services social and

emotional wellness and healthy and safe

physical environmentswwwcdcgov1052011

Building sustainable healthy

communities Bottom line

Obesity is an environmental problem

Despite progress in genetic research public health advances only will occur when we take the environment seriously

Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment

Until we do this we will not make substantial progress in addressing the epidemic of obesity

Poston amp Foreyt Atherosclerosis 1999

Whatrsquos the best approach

Integrate all sectors of society into community

change interventions

Incorporate

Science amp Technology

Education

FamilyCommunity

Healthcare

Arts amp Entertainment

Law amp Politics

Commerce amp Trade

Sectors of Society

Arts amp Entertainm

ent

Commerce amp Trade

Education

FamilyCommunity

Healthcare

Law amp Politics

Science amp Technology

Project FIT rationale design and baseline characteristics of a school- and community-

based intervention to address physical activity and healthy eating among low-income

elementary school children

Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D

Oh HJ Orth J Randall S Mayfield K Holmes D

Source

Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu

Abstract

BACKGROUND

This paper describes Project FIT a collaboration between the public school system local

health systems physicians neighborhood associations businesses faith-based leaders

community agencies and university researchers to develop a multi-faceted approach to

promote physical activity and healthy eating toward the general goal of preventing and

reducing childhood obesity among children in Grand Rapids MI USA

METHODSDESIGN

There are four overall components to Project FIT school community social marketing and

school staff wellness - all that focus on 1) increasing access to safe and affordable physical

activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)

improving the affordability and availability of nutritious food in the neighborhoods surrounding

the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding

nutrition and physical activity among school staff parents and students 4) impacting the

culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging

dialogue among all community partners to leverage existing programs and introduce new

ones

Sectors of Society

Arts amp Entertainment

Commerce amp Trade

Education

FamilyCommunity

Healthcare

Law amp Politics

Science amp Technology

Law and Politics

ldquoLetrsquos Moverdquo Campaign

In the end as First Lady

this isnrsquot just a policy issue

for me This is a passion

This is my mission I am

determined to work with

folks across this country to

change the way a

generation of kids thinks

about food and nutrition

Education

National School Lunch Program

Farmersrsquo Markets

Commerce and Trade

Science amp Technology

WiiFit

X-box

Kinect

Nike run

Health

Blogs

Phone Apps

Arts and Entertainment

Walking School

BusKids used to walk to school all the time Whatley says Now its almost impossible And with childhood obesity rates on the rise Whatley says walking is important because its the easiest way to exercise for a lifetime

FamilyCommunity

Health Care

Results of Lifestyle Interventions for

Weight Loss

ldquoThose who complete weight-loss programs lose approximately 10 of their body weight only to regain two-thirds of it back within one year and almost all of it back within 5 yearsrdquo

Institute of Medicine Weighing the options Criteria for evaluating

weight management programs 1995

Weekly group sessions over 4 ndash 6 months

Mean post-treatment weight reductions of ~ 8-10

Attrition rates are high at 2-yrs (mean = 39 range 20-65)

Attrition rates beyond 2-yrs (mean = 65)

Perri Foreyt amp Anton Preventing Weight

Regain After Weight Loss 2008

Results of Lifestyle Interventions for

Weight Loss

Results of Lifestyle Interventions

Pattern of Weight Regain

Weight regain occurs steadily over 2-5 yrs

Long-term follow-ups of behavioral interventions show a reliable pattern of gradual regaining of lost weight

Long-term losses of ge 5 Kg are sustained in less than 20 of patients in behavioral treatment

Perri Foreyt amp Anton Preventing Weight

Regain After Weight Loss 2008

Results of Lifestyle Interventions

Pattern of Weight Regain

ldquoThe difficulty associated with

maintaining lost weight appears to

be the result of physiological

environmental and psychological

factors that combine to facilitate a

regaining of lost weight and an

abandonment of weight control

effortsrdquo

Perri Foreyt amp Anton 2008

Population-wide prevention of obesity

Small changes in diet and physical activity may make more sense than focusing on large behavioral changes

By cutting 100 calories a day adults can prevent weight gain

Hill et al Science 2003 Hill AJCN 2009

BENEFITS OF MODEST WEIGHT LOSS

ldquoSeveral studies demonstrate that small losseshelliphelp reduce obesity-related co-morbidities and that improvements in these risk factors persist with maintenance of these modest weight lossesrdquo

Institute of Medicine 1995

- Glucose levels - HDL cholesterol levels

- Insulin levels - LDL cholesterol levels

- Glycated hemoglobin - Blood pressure

- Triglyceride levels - Quality of life levels

Stigmatization amp Discrimination

Societal beliefs that weight can be controlled thereby suggestive of character deficits (lack of willpower laziness and emotional problems)

Negative attitudes

ldquoLast safe prejudicerdquo in US society

Rand CSW Macgregor AMC South Med J 1990

DISCRIMINATION

THE PAIN OF OBESITY

Former severely obese patients

100 preferred to be deaf dyslexic

diabetic or have heart disease or bad

acne than to be obese again

Leg amputation was preferred by

915 and blindness by 894

100 preferred to be a normal weight

person rather than a severely obese

multi-millionaire Rand CSW Macgregor AMC Int J Obes 199115577ndash579

Psychosocial Burden of Obesity

Obese individuals often feel misunderstood neglected and rejected

Obese individuals have low employment prospects and are denied educational vocational and advancement opportunities

Significantly poorer quality of life

van Hout GCM van Oudheusden I amp van Heck GL Obes Surg 2004

A Healthy Lifestyle is All About

Balance

Healthy Diet

Healthy Physical Activity

Building Sustainable Healthy

Communities

Healthy Lifestyle

Building Sustainable Healthy

Communities

Healthy Lifestyle

UNFORTUNATELYhellip

Big Texan Steak Ranch

Amarillo Texas

72-oz Steak FREE if eaten within 1 hour

AVERAGE ADULT AMERICAN MAN

Height 5rsquo 8rdquo

Weight 195 lbs

Waist 397 in

BMI 284

CDC 2011

AVERAGE ADULT AMERICAN WOMAN

Height 5rsquo3rdquo

Weight 165 lbs

Waist 370 in

BMI 261

CDC 2011

Miss America

2008

Kirsten Haglund

BMI 1629

Eliana Ramos

Age 18

Height 5rsquo9rdquo

29th OLYMPIAD

BEIJING CHINA

US wrestling team captain Daniel

Cormier (2115 lbs) hospitalized for

kidney failure as result of

dehydration related to cutting weight

(did not compete)

US boxer Gary Russell was found

unconscious 4 days before his

Olympic bout due to cutting weight

(did not compete)

29th OLYMPIAD

BEIJING CHINA

Michael Phelps

8 Gold Medals SwimmingAge 23

Height 6rsquo4rdquo

Weight 195 lbs

BMI 2374

Daily Food Intake 10375 KCAL

(15 PRO 58 CHO 27 FAT)

Exercise 30 hrswk

2005 USDA FOOD PYRAMID

ldquoThe food pyramid

is too complicated

and has too many

messagesrdquo

Robert Post PhD USDA Deputy

Director 2011

2005 USDA FOOD PYRAMID

ldquoItrsquos going to be hard not to do

better than the current pyramid

which basically conveys no

useful informationrdquo

Walter C Willett MD

Chairman Department of Nutrition

Harvard School of Public Health

2011 USDA MY PLATE

ldquoWe are all

bombarded with so

many dietary

messages that it is

hard to find time to

sort through all this

informationrdquo

Michelle Obama 2011

Dietary Guidelines for Americans

2010 Two Primary Concepts

Maintain calorie balance over time to

achieve and maintain a healthy weight

Focus on consuming nutrient-dense foods

and beverages

Dietary Guidelines for Americans 2010

Efficacy-based comparative dietary guidelines

Carb Fat Pro

Mediterranean Diet 45-55 25-35 20

IOM Dietary Ref Intakes 45-65 25-35 15

NCEP-ATPIII 50-60 25-35 15

Am Dietetic Assoc 45-65 20-35 15

PARADOX OF INCREASING OBESITY

PREVALENCE

bull Focus on healthy eating and physical

activity

bull Awareness of dangers of obesity buthellip

bull Obesity prevalence continues to rise

bull Work amp commuting demands

bull Little time to exercise

bull Little time to prepare food

bull Availability of high-fatcalorie foods

Rationale for community-based interventions

bull Increases in obesity prevalence due to genes

bull Increased calories (eg 200 Kcalday

over 10 years)

bull Increased portion sizes (eg 22 oz

steaks and 44 oz sodas)

bull Western diets in developing nations

increase risk of obesity

READINESS TO CHANGE

ldquoHabit is habit and not to be

flung out of the window but

coaxed downstairs a step at a

timerdquo

Mark Twain

Long-Term Weight Maintenance

National Weight Control Registry (N=10000)

Survey of 3000 members who have been in the

Registry for at least 10 years

Starting weight = 224 lbs Average weight loss=69

lbs

At 5 years participants had maintained an average

weight loss=52 lbs

At 10 years participants had maintained an average

weight loss=51 lbs

Thomas Bond Phelan et al TOS 2011

Long-Term Weight Maintenance

Weight Maintainers report that they usually

Track their food intake

Count calories or fat grams

Follow a low-calorie low fat diet (1800 caloriesday

less than 30 of calories from fat

Eat breakfast regularly

Limit the amount they eat out (about 3 timesweek

eat fast food less than onceweek)

Thomas Bond Phelan et al TOS 2011

Long-Term Weight Maintenance

Weight Maintainers report that they usually

Eat similar food regularly

Donrsquot splurge much on holidays amp special occasions

Walk about one hourday

Watch less than 10 hours of TV a week

Weigh themselves at least once a week

Thomas Bond Phelan et al TOS 2011

LONG-TERM WEIGHT MAINTENANCE

Continued consumption of a low-

calorie diet with moderate fat intake

Limited fast food

High levels of physical activity

Phalen et al Obesity 2006 14 710-716

LONG-TERM WEIGHT MAINTENANCE

Daily weighing improved

maintenance of weight loss

particularly when delivered

face to face

Wing et al NEJM 2006 3551563-1571

Most Promising Strategies For

Preventing Weight Regain

Providing multi-component

programs with ongoing

professional contacts

Physical activityexercise

Portion controlmeal replacements

Extending treatment through

weekly or bi-weekly sessions

Pharmacotherapy

Perri Foreyt amp Anton Preventing Weight Regain After Weight Loss 2008

Most Promising Strategies For

Preventing Weight Regain

Extended treatments have shown

promise in promoting adherence to

the behaviors required for the long-

term maintenance of weight loss

Continuous care approach focused

on reasonable long-term objectives

appears appropriate for most

patients

Perri Foreyt amp Anton Preventing Weight Regain After Weight

Loss 2008

An Example of a successful long-term

intervention

The Look AHEAD Study

Does Weight Loss Reduce

Cardiovascular Disease and Death in

Overweight Individuals with Diabetes

bull Action for HEAlth in Diabetes

bull Objective to examine in overweight

persons with Type 2 Diabetes the long-

term effects of an intensive lifestyle

intervention program compared to

diabetes education and support

bull 16 Centers

bull 5145 overweight volunteers with

diabetes

Look AHEAD

Look AHEAD

Primary End Point Composite

bull Cardiovascular death (including fatal

myocardial infarction and stroke)

bull Non-fatal myocardial infarction

bull Non-fatal stroke

Winston-Salem

Baltimore

Philadelphia

New York

Providence

Boston

Clinical Site Coordinating Center

Clinical Sites

Seattle

Los Angeles

San AntonioHouston

Baton Rouge

Minneapolis

Memphis

Birmingham

Pittsburgh

Denver

Phoenix

Look AHEADParticipants

101100Baseline weight (kg)

589586Age (years)

9496Attended 1 year exam

360359Baseline BMI

1514Insulin Users

3737Minority

6059Women

(N=2574)(N=2630)

DSELifestyle

p lt 0004

Look AHEAD

Study Interventions

bull Diabetes support and education - DSE (control group)

bull Lifestyle intervention ndash ILI (treatment group)

Look AHEAD

Lifestyle Intervention

Goals

bull 7 weight loss for the group (10

for individual)

bull 175 minutes of moderate intensity

activity

Look AHEAD

Lifestyle Intervention

bull Diet

ndash ADA NCEP (lt 30 fat lt 10 sat fat

gt15 protein)

ndash 1200-1500 (if weight lt250lbs)

ndash 1500-1800 (if weight gt250lbs)

ndash During first 4 weeks to 4 months portion

control (liquid meal replacements or

structured meal plan)

Look AHEAD

Lifestyle Intervention

bull Physical Activity

ndash unsupervised

ndash 175 minutes moderate intensityweek

ndash 5 daysweek

ndash walking

Weight Loss at 1-Year

-9

ILI 0

-1

-2

-3

-4

-5

-6

-7

-8

DSE

p lt 00001

W

eig

ht

Chan

ge

86

07

The Look AHEAD Research Group Diabetes Care 2007

Reduction in Initial Weight by Gender

N=872

N=1229N=1197

N=830

-12

-10

-8

-6

-4

-2

0

0 2 4 6 8 10 12

Months

R

ed

uctio

n in

In

itia

l W

eig

ht

Men

Women

Plt0001

The Look AHEAD Research Group Diabetes Care 2007

Fitness Change () at 1-Year

0

5

10

15

20

25

Mean

Fitness C

hange

Unadjusted

Plt0001Adjusted for 1 Year

Weight Change Plt0001

58

209

108

159

DSE ILI ILIDSE

The Look AHEAD Research Group Diabetes Care 2007

1-Year Changes in Markers of

Diabetes Control

Markers of Diabetes

Control ILI DSE P-value

Hemoglobin A1c () BL

Hemoglobin A1c () Y1

Y1 ndash Baseline

725

661

-064

729

715

-014

026

lt0001

lt0001

Fasting glucose (mgdl) BL

Fasting glucose (mgdl) Y1

Y1 ndash Baseline

1519

1304

-215

1536

1464

-72

021

lt0001

lt0001

Diabetes medications BL

Diabetes medications Y1

Y1 ndash Baseline

865

786

-78

865

887

22

093

lt0001

lt0001

1-Year Changes in Markers of

Blood Pressure ControlMarkers of Blood Pressure

Control ILI DSE P-value

Systolic BP (mmHg) BL

Systolic BP (mmHg) Y1

Y1 ndash Baseline

1282

1214

-68

1294

1266

-28

026

lt0001

lt0001

Diastolic BP (mmHg) BL

Diastolic BP (mmHg) Y1

Y1 ndash Baseline

699

670

-30

704

686

-18

011

lt0001

lt0001

Antihypertensive medications BL

Antihypertensive medications Y1

Y1 ndash Baseline

753

752

-01

737

759

22

023

054

002

1-Year Changes in Markers of Lipid

Control

Markers of Lipid Control ILI DSE P-value

LDL-cholesterol (mgdl) BL

LDL-cholesterol (mgdl) Y1

Y1 ndash Baseline

1122

1070

-52

1124

1067

-57

078

074

049

HDL-cholesterol (mgdl) BL

HDL-cholesterol (mgdl) Y1

Y1 ndash Baseline

435

469

34

436

449

14

080

lt0001

lt0001

Triglycerides (mgdl) BL

Triglycerides (mgdl) Y1

Y1 ndash Baseline

1828

1525

-303

1800

1654

-146

038

lt0001

lt0001

Lipid lowering medications BL

Lipid lowering medications Y1

Y1 ndash Baseline

494

530

37

484

578

94

052

lt0001

lt0001

1-Year Changes in Percent of Participants

Meeting ADA Goals

ADA Goal ILI DSE P-value

Hemoglobin A1c lt 7 BL

Hemoglobin A1c lt 7 Y1

Y1 ndash Baseline

463

727

264

454

508

54

050

lt0001

lt0001

Blood pressure lt 13080 mmHg BL

Blood pressure lt 13080 mmHg Y1

Y1 ndash Baseline

535

686

151

499

570

70

001

lt0001

lt0001

LDL-cholesterol lt 100 mgdl BL

LDL-cholesterol lt 100 mgdl Y1

Y1 ndash Baseline

371

438

67

369

449

80

087

045

034

All three goals BL

All three goals Y1

Y1 ndash Baseline

108

236

128

95

160

65

013

lt0001

lt0001

Mean Changes in Weight Fitness amp BP

Averaged Over Four Years

DSE

Mean

ILI

Mean

P-value

Weight Loss

( initial wt)

-088 -615 lt 00001

Fitness

( METS)

196 1274 lt00001

HbA1c -009 -036 lt 00001

SBP (mm Hg) -297 -533 lt 00001

DBP (mm Hg) -248 -292 0012

Look AHEAD Research Group Arch Int Med 2010

Mean Changes in Lipid Profile

Averaged Over Four Years

DSE

Mean

ILI

Mean

P-value

HDL (mgdl) 197 367 lt00001

TG (mgdl) -1975 -2556 00006

LDL (mgdl) -1284 -1127 0009

LDL (mgdl)

(Adjusting for

medication use)

-922 -875 042

Look AHEAD Research Group Arch Int Med 2010

Percent () Completing Outcome

Measures at Years 1-4

Intervention Group

(ILI)

Year 1 971

Year 2 949

Year 3 940

Year 4 941

Comparison Group

(DSE)

Year 1 957

Year 2 935

Year 3 938

Year 4 931

Look AHEAD Summary

ILI had significantly greater improvements than DSE in all CVD risk factors averaged across 4 years (except LDL-C)

There may be long-term beneficial effects from this 4-year period in which ILI subjects have been exposed to lower CVD risk factors

Longer follow-ups will determine whether these lowered CVD risk factors can be maintained amp whether lifestyle intervention has positive effects on CVD morbidity amp mortality

Mary J

Female

White

56 years old at start of Look AHEAD

study

Past Medical History Type 2 diabetes

overweight diverticulosis arthritis

sleep apnea back pain

Mary J

bullLong term strugglesbull Helping youngest daughter with

personal issues and children

bull Rotator cuff problems

bull Degenerative disks in back

bull Rheumatoid arthritis

bull Diabetes

bull Physically demanding job

bull Financial struggles

Pounds

Years

82007 grandkids enter pre-school

Catherine L

Female

White

47 years old at start of Look AHEAD

study

Past Medical History Type 2 diabetes

overweight high blood pressure

hypothyroidism back pain

Catherine L

Long term struggles

bull Motherrsquos declining health and death

bull Multiple serious injuries

bull Sudden death of sister

bull Death of step-father

bull Declining economy

bull Children living at home

Pounds

Years

Realistic Management Goals

5-10 weight loss

Health energy and fitness

Well-being and self-esteem

Mood and appearance

Functional and recreational

activity

Key Elements

Focus on health and energy

Food and physical activity diaries

Gradual increase in physical activity

Gradual reduction in dietary fat

No feelings of food deprivation

Social support groups

Recommended Strategies for Building

Sustainable Healthy Communities

Overview from USA

Promote the availability of affordable healthy

food and beverages

Support healthy food and beverage choices

Encourage breastfeeding

Encourage physical activity or limit sedentary

activity among children amp youth

Create safe communities that support physical

activity

Encourage communities to organize for change

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Increase the availability of healthier food and

beverage choices in public service venues (eg

schools city amp county buildings etc)

--Insufficient evidence in school-based programs

--Associations suggest availability amp increased

consumption

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve availability of affordable healthier

food amp beverage choices in public service

venues

--Reducing the cost of healthier foods

increases their purchase

--Providing coupons redeemable for

healthier foods increases their purchase

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve geographic availability of

supermarkets in underserved areas

-- Greater access to nearby supermarkets is

associated with healthier eating behaviors

-- Increasing the number of supermarkets in

underserved neighborhoods increased

real estate values increased economic

activity amp employment amp resulted in lower

food prices

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Provide incentives to food retailers to locate in

andor offer healthier food choices in

underserved areas

-- Presence of retail venues that provide healthier

foods is associated with better nutrition

-- Greater availability of supermarkets was

associated with lower adolescent BMI scores

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Improve availability of mechanisms for

purchasing foods from farms

--Evidence supporting a direct link between

purchasing food from farms amp improved diet is

limited

--Two studies of initiatives to encourage

participation in farmersrsquo market showed

increased intention to eat more fruits amp

vegetables but no direct evidence

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Provide incentives for the production

distribution and procurement of foods from local

farms

--No evidence has been published to link local

food production amp health outcomes

--There is a current study exploring the potential

nutritional amp health benefits of eating locally

grown foods

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Restrict availability of less healthy foods amp

beverages in public service venues

--No peer-reviewed studies examined the impact

designed to restrict availability of less healthy

foods in public service venues

--21 states have policies that restrict the sale of

competitive foods in schools beyond USDA

regulations however no studies have evaluated

the impact of the policies

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Institute smaller portion size options in public

service venues

--Evidence is lacking to demonstrate effectiveness

of population-based interventions aimed at

reducing portion sizes in public service venues

--Evidence from clinical studies in laboratories

demonstrates decreasing portion sizes

decreases energy intake

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Limit advertisements of less healthy foods amp

beverages

--Little evidence is available regarding the impact

of restricting advertising on purchasing amp

consumption of less healthy foods

--Cross-sectional time-series studies of tobacco-

control efforts suggest an association between

advertising bans amp decreased tobacco

consumption

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Discourage consumption of sugar-sweetened

beverages

--One longitudinal study of a school-based

intervention among Native-American high school

students showed a substantial reduction in

sugar-sweetened beverages over a 3-year

period

--A RCT of a home-based intervention that

eliminated sugar-sweetened beverages showed

reduction in BMI scores

Recommended Community Strategies Strategies to encourage breastfeeding

Increase support for breastfeeding

--Evidence directly linking environmental

interventions that support breastfeeding with

obesity-related outcomes is lacking

--Epidemiologic studies indicate that breastfeeding

helps prevent pediatric obesity

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Require physical education in schools

--14 studies have demonstrated that school-based

PE was effective in increasing levels of physical

activity and improving physical fitness

--Minimum of 150 minwk in elementary schools

225 minwk in middle schools and high schools

throughout the school year as recommended by

NASPE

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Increase opportunities for extracurricular

physical activity

--Participation in after-school programs increased

studentsrsquo level of physical activity amp improved

obesity-related outcomes (improved CV fitness

reduced body fat)

--2 pilot studies providing extracurricular physical

activity showed increased levels of PA amp

decreased sedentary behavior

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Reduce screen time in public service venues

--A school-based RCT indicated that children who

reduced their television videotape amp video

game use had significant decrease in BMI tricep

skin fold thickness amp waist circumference

compared to controls

--Spending less time watching television is

associated with increased physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Improve access to outdoor recreational

facilities

--Review of 108 studies indicated that access to facilities

and programs for recreation near their homes amp time

spent outdoors correlated positively with increased

physical activity among childrenamp adults

--Perceptions that footpaths are safe for walking was

significantly associated with adults being classified as

physically active at a level sufficient for health benefits

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting

bicycling

--Longitudinal intervention studies have

demonstrated that improving bicycling

infrastructure is associated with increased

frequency of bicycling

--Cross-sectional studies indicated a significant

association between bicycling infrastructure amp

frequency of biking

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting walking

--Reviews of cross-sectional studies of

environmental correlates of physical activity amp

walking generally find a positive association

between infrastructure supportive of walking amp

physical activity

--Identifying amp creating safe routes to school

together with educational components

increased the number of students walking to

school

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Locating schools within easy walking

distance of residential areas

--Community-scale urban design amp land use policies amp

practices including locating schools stores workplaces

amp recreation areas close to residential areas are

effective in facilitating an increase in levels of physical

activity

--Majority of efforts to encourage walking to school involve

improving the routes rather than improving the location

of schools

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Improve access to public transportation

--Insufficient evidence exists to determine

effectiveness of transportation policies in

increasing the level of physical activity or

improving fitness

--1 study indicated that 29 of individuals who

walk to and from public transit achieve at least

30 minutes of daily physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Zone for mixed-use development

--Allows residential commercial institutional amp

other public land uses to be located in close

proximity to one another

--Studies using correlation analyses amp regression

models indicated that mixed land use was

associated with increased walking amp cycling

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance personal safety in areas where

persons are or could be physically active

--Cross-sectional studies have demonstrated a

negative relationship between crime rates andor

perceived safety amp physical activity in

neighborhoods

--Few intervention studies have evaluated the

impact of policies amp practices to improve

personal safety on physical activity

Geospatial Mapping Linking Urban

Environments to Health Risk

Measure association between environmental variables amp health risk factors

Assess relationships between variables at different levels of analysis

Used in conjunction with linear analyses

Our Community Environmental Model

of Obesity

Community Factors

Poverty

Crime

Grocery Quality

Restaurants

Parks

Sidewalks

Fast Food Outlets

Recreational

Facilities

Individual Factors

Dietary Intake

Physical Activity

Genetics

Family History

StressCoping

Eating Disorders

Psychological

Problems

Weight

Status

Chosen Neighborhoods

Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped

We then matched census-block groups within the income groups by population density and percentage of minority representation

One matched block group per income level was randomly selected

Prevalence of Obesity in

Block-Groups

0

5

10

15

20

25

30

35

40

45

50

Ag

e-a

dju

sted

Ob

esit

y P

rev

ale

nce

(

)

High-Income Low-Income

Age-standardized to the 1990 US Census

Density of Environmental Factors in the

Community Contributes to a ldquoToxicrdquo

Obesity Environment

0

2

4

6

8

10

12

14

16

18

Fast-food Convenience Store Bars

Den

sity

10

00

perso

ns

High-Income Low-Income

COMMUNITYrsquoS PERCEPTION OF SAFETY

0

5

10

15

20

25

30

35

40

Daytime Nighttime

Perc

en

t (

) F

eeli

ng

So

mew

hat

Safe

or

Un

safe

Low-Income High-Income

Percent Substandard (or worse) Housing

or Ground Conditions

of Residential Properties

0

10

20

30

Structural Grounds

Perc

en

t (

)

Low-Income High-Income

CONCLUSIONS

These data suggest that the higher

frequency of outlets providing

calorically-dense foods and alcohol may

contribute to greater obesity prevalence

in residents of low-income communities

More research is needed to thoroughly

document environmental determinants

of health and obesity

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

From 1994-1998 HUD randomly assigned

4498 women with children living in public

housing in high-poverty urban census

tracts to one of three groups (1) housing

vouchers redeemable only if they moved

to a low-poverty census tract (2)

unrestricted vouchers or (3) control group

(no vouchers)

Ludwig et al NEJM 201136516

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

10-12 year follow-up showed modest but

potentially important reductions in the

prevalence of extreme obesity amp diabetes in the

group moving from a neighborhood with high

poverty on one of low poverty compared to the

control group

No differences between the group receiving

traditional vouchers amp the control group

ldquoNeighborhoods matterrdquo

Ludwig et al NEJM 201136516

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance traffic safety in areas where

persons are or could be physically active

--Community-scale urban design amp land use policies to

promote physical activity including design components

to improve street lighting infrastructure projects to

increase safety of pedestrian street crossing and use of

traffic calming approaches such as speed humps amp

traffic circles are effective in increasing physical activity

--Both community-scale amp street-scale policies amp practices

are effective in increasing physical activity

Recommended Community Strategies Encourage Communities to Organize for Change

Participate in community coalitions or

partnerships to address obesity

--Little evidence is available to determine the

impact of community coalitions on obesity

prevention

--The presence of anti-smoking community

coalitions has been associated with lower rates

of tobacco consumption

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

$103 million awarded to 61 states and

communities including state amp local government

agencies tribes amp territories amp state amp local non-

profit organizations

To build capacity to implement changes for

community prevention efforts to ensure long-

term success

To implement evidence-based and practice-

based programs to improve health amp wellness

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Priority areas are

Tobacco-free living

Active living and healthy eating

Evidence-based quality clinical and other

preventive health services for prevention

and control of high blood pressure and

high cholesterol

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Applicants proposed specific activities in

line with their chosen priority areas in their

applications

Grantee activities will not be finalized until

plans are negotiated with CDC by early

2012

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Capacity-Building Award

The Confederated Tribes of The Chehalis

Reservation is receiving a $498663 planning

award to build capacity to support healthy

lifestyles among their tribal population of 1500

in Washington State

Work will target tobacco-free living active living

and healthy eating and quality clinical and other

healthy serviceswwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Implementation Award

Austin TX Dept of Health and Human Services

is receiving $1026158 to serve Travis County

(Austin) to expand efforts in tobacco-free living

active living and healthy eating quality clinical

and other preventive services social and

emotional wellness and healthy and safe

physical environmentswwwcdcgov1052011

Building sustainable healthy

communities Bottom line

Obesity is an environmental problem

Despite progress in genetic research public health advances only will occur when we take the environment seriously

Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment

Until we do this we will not make substantial progress in addressing the epidemic of obesity

Poston amp Foreyt Atherosclerosis 1999

Whatrsquos the best approach

Integrate all sectors of society into community

change interventions

Incorporate

Science amp Technology

Education

FamilyCommunity

Healthcare

Arts amp Entertainment

Law amp Politics

Commerce amp Trade

Sectors of Society

Arts amp Entertainm

ent

Commerce amp Trade

Education

FamilyCommunity

Healthcare

Law amp Politics

Science amp Technology

Project FIT rationale design and baseline characteristics of a school- and community-

based intervention to address physical activity and healthy eating among low-income

elementary school children

Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D

Oh HJ Orth J Randall S Mayfield K Holmes D

Source

Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu

Abstract

BACKGROUND

This paper describes Project FIT a collaboration between the public school system local

health systems physicians neighborhood associations businesses faith-based leaders

community agencies and university researchers to develop a multi-faceted approach to

promote physical activity and healthy eating toward the general goal of preventing and

reducing childhood obesity among children in Grand Rapids MI USA

METHODSDESIGN

There are four overall components to Project FIT school community social marketing and

school staff wellness - all that focus on 1) increasing access to safe and affordable physical

activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)

improving the affordability and availability of nutritious food in the neighborhoods surrounding

the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding

nutrition and physical activity among school staff parents and students 4) impacting the

culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging

dialogue among all community partners to leverage existing programs and introduce new

ones

Law and Politics

ldquoLetrsquos Moverdquo Campaign

In the end as First Lady

this isnrsquot just a policy issue

for me This is a passion

This is my mission I am

determined to work with

folks across this country to

change the way a

generation of kids thinks

about food and nutrition

Education

National School Lunch Program

Farmersrsquo Markets

Commerce and Trade

Science amp Technology

WiiFit

X-box

Kinect

Nike run

Health

Blogs

Phone Apps

Arts and Entertainment

Walking School

BusKids used to walk to school all the time Whatley says Now its almost impossible And with childhood obesity rates on the rise Whatley says walking is important because its the easiest way to exercise for a lifetime

FamilyCommunity

Health Care

Results of Lifestyle Interventions for

Weight Loss

ldquoThose who complete weight-loss programs lose approximately 10 of their body weight only to regain two-thirds of it back within one year and almost all of it back within 5 yearsrdquo

Institute of Medicine Weighing the options Criteria for evaluating

weight management programs 1995

Weekly group sessions over 4 ndash 6 months

Mean post-treatment weight reductions of ~ 8-10

Attrition rates are high at 2-yrs (mean = 39 range 20-65)

Attrition rates beyond 2-yrs (mean = 65)

Perri Foreyt amp Anton Preventing Weight

Regain After Weight Loss 2008

Results of Lifestyle Interventions for

Weight Loss

Results of Lifestyle Interventions

Pattern of Weight Regain

Weight regain occurs steadily over 2-5 yrs

Long-term follow-ups of behavioral interventions show a reliable pattern of gradual regaining of lost weight

Long-term losses of ge 5 Kg are sustained in less than 20 of patients in behavioral treatment

Perri Foreyt amp Anton Preventing Weight

Regain After Weight Loss 2008

Results of Lifestyle Interventions

Pattern of Weight Regain

ldquoThe difficulty associated with

maintaining lost weight appears to

be the result of physiological

environmental and psychological

factors that combine to facilitate a

regaining of lost weight and an

abandonment of weight control

effortsrdquo

Perri Foreyt amp Anton 2008

Population-wide prevention of obesity

Small changes in diet and physical activity may make more sense than focusing on large behavioral changes

By cutting 100 calories a day adults can prevent weight gain

Hill et al Science 2003 Hill AJCN 2009

BENEFITS OF MODEST WEIGHT LOSS

ldquoSeveral studies demonstrate that small losseshelliphelp reduce obesity-related co-morbidities and that improvements in these risk factors persist with maintenance of these modest weight lossesrdquo

Institute of Medicine 1995

- Glucose levels - HDL cholesterol levels

- Insulin levels - LDL cholesterol levels

- Glycated hemoglobin - Blood pressure

- Triglyceride levels - Quality of life levels

Stigmatization amp Discrimination

Societal beliefs that weight can be controlled thereby suggestive of character deficits (lack of willpower laziness and emotional problems)

Negative attitudes

ldquoLast safe prejudicerdquo in US society

Rand CSW Macgregor AMC South Med J 1990

DISCRIMINATION

THE PAIN OF OBESITY

Former severely obese patients

100 preferred to be deaf dyslexic

diabetic or have heart disease or bad

acne than to be obese again

Leg amputation was preferred by

915 and blindness by 894

100 preferred to be a normal weight

person rather than a severely obese

multi-millionaire Rand CSW Macgregor AMC Int J Obes 199115577ndash579

Psychosocial Burden of Obesity

Obese individuals often feel misunderstood neglected and rejected

Obese individuals have low employment prospects and are denied educational vocational and advancement opportunities

Significantly poorer quality of life

van Hout GCM van Oudheusden I amp van Heck GL Obes Surg 2004

A Healthy Lifestyle is All About

Balance

Healthy Diet

Healthy Physical Activity

Building Sustainable Healthy

Communities

Healthy Lifestyle

Building Sustainable Healthy

Communities

Healthy Lifestyle

UNFORTUNATELYhellip

Big Texan Steak Ranch

Amarillo Texas

72-oz Steak FREE if eaten within 1 hour

AVERAGE ADULT AMERICAN MAN

Height 5rsquo 8rdquo

Weight 195 lbs

Waist 397 in

BMI 284

CDC 2011

AVERAGE ADULT AMERICAN WOMAN

Height 5rsquo3rdquo

Weight 165 lbs

Waist 370 in

BMI 261

CDC 2011

Miss America

2008

Kirsten Haglund

BMI 1629

Eliana Ramos

Age 18

Height 5rsquo9rdquo

29th OLYMPIAD

BEIJING CHINA

US wrestling team captain Daniel

Cormier (2115 lbs) hospitalized for

kidney failure as result of

dehydration related to cutting weight

(did not compete)

US boxer Gary Russell was found

unconscious 4 days before his

Olympic bout due to cutting weight

(did not compete)

29th OLYMPIAD

BEIJING CHINA

Michael Phelps

8 Gold Medals SwimmingAge 23

Height 6rsquo4rdquo

Weight 195 lbs

BMI 2374

Daily Food Intake 10375 KCAL

(15 PRO 58 CHO 27 FAT)

Exercise 30 hrswk

2005 USDA FOOD PYRAMID

ldquoThe food pyramid

is too complicated

and has too many

messagesrdquo

Robert Post PhD USDA Deputy

Director 2011

2005 USDA FOOD PYRAMID

ldquoItrsquos going to be hard not to do

better than the current pyramid

which basically conveys no

useful informationrdquo

Walter C Willett MD

Chairman Department of Nutrition

Harvard School of Public Health

2011 USDA MY PLATE

ldquoWe are all

bombarded with so

many dietary

messages that it is

hard to find time to

sort through all this

informationrdquo

Michelle Obama 2011

Dietary Guidelines for Americans

2010 Two Primary Concepts

Maintain calorie balance over time to

achieve and maintain a healthy weight

Focus on consuming nutrient-dense foods

and beverages

Dietary Guidelines for Americans 2010

Efficacy-based comparative dietary guidelines

Carb Fat Pro

Mediterranean Diet 45-55 25-35 20

IOM Dietary Ref Intakes 45-65 25-35 15

NCEP-ATPIII 50-60 25-35 15

Am Dietetic Assoc 45-65 20-35 15

PARADOX OF INCREASING OBESITY

PREVALENCE

bull Focus on healthy eating and physical

activity

bull Awareness of dangers of obesity buthellip

bull Obesity prevalence continues to rise

bull Work amp commuting demands

bull Little time to exercise

bull Little time to prepare food

bull Availability of high-fatcalorie foods

Rationale for community-based interventions

bull Increases in obesity prevalence due to genes

bull Increased calories (eg 200 Kcalday

over 10 years)

bull Increased portion sizes (eg 22 oz

steaks and 44 oz sodas)

bull Western diets in developing nations

increase risk of obesity

READINESS TO CHANGE

ldquoHabit is habit and not to be

flung out of the window but

coaxed downstairs a step at a

timerdquo

Mark Twain

Long-Term Weight Maintenance

National Weight Control Registry (N=10000)

Survey of 3000 members who have been in the

Registry for at least 10 years

Starting weight = 224 lbs Average weight loss=69

lbs

At 5 years participants had maintained an average

weight loss=52 lbs

At 10 years participants had maintained an average

weight loss=51 lbs

Thomas Bond Phelan et al TOS 2011

Long-Term Weight Maintenance

Weight Maintainers report that they usually

Track their food intake

Count calories or fat grams

Follow a low-calorie low fat diet (1800 caloriesday

less than 30 of calories from fat

Eat breakfast regularly

Limit the amount they eat out (about 3 timesweek

eat fast food less than onceweek)

Thomas Bond Phelan et al TOS 2011

Long-Term Weight Maintenance

Weight Maintainers report that they usually

Eat similar food regularly

Donrsquot splurge much on holidays amp special occasions

Walk about one hourday

Watch less than 10 hours of TV a week

Weigh themselves at least once a week

Thomas Bond Phelan et al TOS 2011

LONG-TERM WEIGHT MAINTENANCE

Continued consumption of a low-

calorie diet with moderate fat intake

Limited fast food

High levels of physical activity

Phalen et al Obesity 2006 14 710-716

LONG-TERM WEIGHT MAINTENANCE

Daily weighing improved

maintenance of weight loss

particularly when delivered

face to face

Wing et al NEJM 2006 3551563-1571

Most Promising Strategies For

Preventing Weight Regain

Providing multi-component

programs with ongoing

professional contacts

Physical activityexercise

Portion controlmeal replacements

Extending treatment through

weekly or bi-weekly sessions

Pharmacotherapy

Perri Foreyt amp Anton Preventing Weight Regain After Weight Loss 2008

Most Promising Strategies For

Preventing Weight Regain

Extended treatments have shown

promise in promoting adherence to

the behaviors required for the long-

term maintenance of weight loss

Continuous care approach focused

on reasonable long-term objectives

appears appropriate for most

patients

Perri Foreyt amp Anton Preventing Weight Regain After Weight

Loss 2008

An Example of a successful long-term

intervention

The Look AHEAD Study

Does Weight Loss Reduce

Cardiovascular Disease and Death in

Overweight Individuals with Diabetes

bull Action for HEAlth in Diabetes

bull Objective to examine in overweight

persons with Type 2 Diabetes the long-

term effects of an intensive lifestyle

intervention program compared to

diabetes education and support

bull 16 Centers

bull 5145 overweight volunteers with

diabetes

Look AHEAD

Look AHEAD

Primary End Point Composite

bull Cardiovascular death (including fatal

myocardial infarction and stroke)

bull Non-fatal myocardial infarction

bull Non-fatal stroke

Winston-Salem

Baltimore

Philadelphia

New York

Providence

Boston

Clinical Site Coordinating Center

Clinical Sites

Seattle

Los Angeles

San AntonioHouston

Baton Rouge

Minneapolis

Memphis

Birmingham

Pittsburgh

Denver

Phoenix

Look AHEADParticipants

101100Baseline weight (kg)

589586Age (years)

9496Attended 1 year exam

360359Baseline BMI

1514Insulin Users

3737Minority

6059Women

(N=2574)(N=2630)

DSELifestyle

p lt 0004

Look AHEAD

Study Interventions

bull Diabetes support and education - DSE (control group)

bull Lifestyle intervention ndash ILI (treatment group)

Look AHEAD

Lifestyle Intervention

Goals

bull 7 weight loss for the group (10

for individual)

bull 175 minutes of moderate intensity

activity

Look AHEAD

Lifestyle Intervention

bull Diet

ndash ADA NCEP (lt 30 fat lt 10 sat fat

gt15 protein)

ndash 1200-1500 (if weight lt250lbs)

ndash 1500-1800 (if weight gt250lbs)

ndash During first 4 weeks to 4 months portion

control (liquid meal replacements or

structured meal plan)

Look AHEAD

Lifestyle Intervention

bull Physical Activity

ndash unsupervised

ndash 175 minutes moderate intensityweek

ndash 5 daysweek

ndash walking

Weight Loss at 1-Year

-9

ILI 0

-1

-2

-3

-4

-5

-6

-7

-8

DSE

p lt 00001

W

eig

ht

Chan

ge

86

07

The Look AHEAD Research Group Diabetes Care 2007

Reduction in Initial Weight by Gender

N=872

N=1229N=1197

N=830

-12

-10

-8

-6

-4

-2

0

0 2 4 6 8 10 12

Months

R

ed

uctio

n in

In

itia

l W

eig

ht

Men

Women

Plt0001

The Look AHEAD Research Group Diabetes Care 2007

Fitness Change () at 1-Year

0

5

10

15

20

25

Mean

Fitness C

hange

Unadjusted

Plt0001Adjusted for 1 Year

Weight Change Plt0001

58

209

108

159

DSE ILI ILIDSE

The Look AHEAD Research Group Diabetes Care 2007

1-Year Changes in Markers of

Diabetes Control

Markers of Diabetes

Control ILI DSE P-value

Hemoglobin A1c () BL

Hemoglobin A1c () Y1

Y1 ndash Baseline

725

661

-064

729

715

-014

026

lt0001

lt0001

Fasting glucose (mgdl) BL

Fasting glucose (mgdl) Y1

Y1 ndash Baseline

1519

1304

-215

1536

1464

-72

021

lt0001

lt0001

Diabetes medications BL

Diabetes medications Y1

Y1 ndash Baseline

865

786

-78

865

887

22

093

lt0001

lt0001

1-Year Changes in Markers of

Blood Pressure ControlMarkers of Blood Pressure

Control ILI DSE P-value

Systolic BP (mmHg) BL

Systolic BP (mmHg) Y1

Y1 ndash Baseline

1282

1214

-68

1294

1266

-28

026

lt0001

lt0001

Diastolic BP (mmHg) BL

Diastolic BP (mmHg) Y1

Y1 ndash Baseline

699

670

-30

704

686

-18

011

lt0001

lt0001

Antihypertensive medications BL

Antihypertensive medications Y1

Y1 ndash Baseline

753

752

-01

737

759

22

023

054

002

1-Year Changes in Markers of Lipid

Control

Markers of Lipid Control ILI DSE P-value

LDL-cholesterol (mgdl) BL

LDL-cholesterol (mgdl) Y1

Y1 ndash Baseline

1122

1070

-52

1124

1067

-57

078

074

049

HDL-cholesterol (mgdl) BL

HDL-cholesterol (mgdl) Y1

Y1 ndash Baseline

435

469

34

436

449

14

080

lt0001

lt0001

Triglycerides (mgdl) BL

Triglycerides (mgdl) Y1

Y1 ndash Baseline

1828

1525

-303

1800

1654

-146

038

lt0001

lt0001

Lipid lowering medications BL

Lipid lowering medications Y1

Y1 ndash Baseline

494

530

37

484

578

94

052

lt0001

lt0001

1-Year Changes in Percent of Participants

Meeting ADA Goals

ADA Goal ILI DSE P-value

Hemoglobin A1c lt 7 BL

Hemoglobin A1c lt 7 Y1

Y1 ndash Baseline

463

727

264

454

508

54

050

lt0001

lt0001

Blood pressure lt 13080 mmHg BL

Blood pressure lt 13080 mmHg Y1

Y1 ndash Baseline

535

686

151

499

570

70

001

lt0001

lt0001

LDL-cholesterol lt 100 mgdl BL

LDL-cholesterol lt 100 mgdl Y1

Y1 ndash Baseline

371

438

67

369

449

80

087

045

034

All three goals BL

All three goals Y1

Y1 ndash Baseline

108

236

128

95

160

65

013

lt0001

lt0001

Mean Changes in Weight Fitness amp BP

Averaged Over Four Years

DSE

Mean

ILI

Mean

P-value

Weight Loss

( initial wt)

-088 -615 lt 00001

Fitness

( METS)

196 1274 lt00001

HbA1c -009 -036 lt 00001

SBP (mm Hg) -297 -533 lt 00001

DBP (mm Hg) -248 -292 0012

Look AHEAD Research Group Arch Int Med 2010

Mean Changes in Lipid Profile

Averaged Over Four Years

DSE

Mean

ILI

Mean

P-value

HDL (mgdl) 197 367 lt00001

TG (mgdl) -1975 -2556 00006

LDL (mgdl) -1284 -1127 0009

LDL (mgdl)

(Adjusting for

medication use)

-922 -875 042

Look AHEAD Research Group Arch Int Med 2010

Percent () Completing Outcome

Measures at Years 1-4

Intervention Group

(ILI)

Year 1 971

Year 2 949

Year 3 940

Year 4 941

Comparison Group

(DSE)

Year 1 957

Year 2 935

Year 3 938

Year 4 931

Look AHEAD Summary

ILI had significantly greater improvements than DSE in all CVD risk factors averaged across 4 years (except LDL-C)

There may be long-term beneficial effects from this 4-year period in which ILI subjects have been exposed to lower CVD risk factors

Longer follow-ups will determine whether these lowered CVD risk factors can be maintained amp whether lifestyle intervention has positive effects on CVD morbidity amp mortality

Mary J

Female

White

56 years old at start of Look AHEAD

study

Past Medical History Type 2 diabetes

overweight diverticulosis arthritis

sleep apnea back pain

Mary J

bullLong term strugglesbull Helping youngest daughter with

personal issues and children

bull Rotator cuff problems

bull Degenerative disks in back

bull Rheumatoid arthritis

bull Diabetes

bull Physically demanding job

bull Financial struggles

Pounds

Years

82007 grandkids enter pre-school

Catherine L

Female

White

47 years old at start of Look AHEAD

study

Past Medical History Type 2 diabetes

overweight high blood pressure

hypothyroidism back pain

Catherine L

Long term struggles

bull Motherrsquos declining health and death

bull Multiple serious injuries

bull Sudden death of sister

bull Death of step-father

bull Declining economy

bull Children living at home

Pounds

Years

Realistic Management Goals

5-10 weight loss

Health energy and fitness

Well-being and self-esteem

Mood and appearance

Functional and recreational

activity

Key Elements

Focus on health and energy

Food and physical activity diaries

Gradual increase in physical activity

Gradual reduction in dietary fat

No feelings of food deprivation

Social support groups

Recommended Strategies for Building

Sustainable Healthy Communities

Overview from USA

Promote the availability of affordable healthy

food and beverages

Support healthy food and beverage choices

Encourage breastfeeding

Encourage physical activity or limit sedentary

activity among children amp youth

Create safe communities that support physical

activity

Encourage communities to organize for change

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Increase the availability of healthier food and

beverage choices in public service venues (eg

schools city amp county buildings etc)

--Insufficient evidence in school-based programs

--Associations suggest availability amp increased

consumption

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve availability of affordable healthier

food amp beverage choices in public service

venues

--Reducing the cost of healthier foods

increases their purchase

--Providing coupons redeemable for

healthier foods increases their purchase

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve geographic availability of

supermarkets in underserved areas

-- Greater access to nearby supermarkets is

associated with healthier eating behaviors

-- Increasing the number of supermarkets in

underserved neighborhoods increased

real estate values increased economic

activity amp employment amp resulted in lower

food prices

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Provide incentives to food retailers to locate in

andor offer healthier food choices in

underserved areas

-- Presence of retail venues that provide healthier

foods is associated with better nutrition

-- Greater availability of supermarkets was

associated with lower adolescent BMI scores

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Improve availability of mechanisms for

purchasing foods from farms

--Evidence supporting a direct link between

purchasing food from farms amp improved diet is

limited

--Two studies of initiatives to encourage

participation in farmersrsquo market showed

increased intention to eat more fruits amp

vegetables but no direct evidence

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Provide incentives for the production

distribution and procurement of foods from local

farms

--No evidence has been published to link local

food production amp health outcomes

--There is a current study exploring the potential

nutritional amp health benefits of eating locally

grown foods

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Restrict availability of less healthy foods amp

beverages in public service venues

--No peer-reviewed studies examined the impact

designed to restrict availability of less healthy

foods in public service venues

--21 states have policies that restrict the sale of

competitive foods in schools beyond USDA

regulations however no studies have evaluated

the impact of the policies

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Institute smaller portion size options in public

service venues

--Evidence is lacking to demonstrate effectiveness

of population-based interventions aimed at

reducing portion sizes in public service venues

--Evidence from clinical studies in laboratories

demonstrates decreasing portion sizes

decreases energy intake

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Limit advertisements of less healthy foods amp

beverages

--Little evidence is available regarding the impact

of restricting advertising on purchasing amp

consumption of less healthy foods

--Cross-sectional time-series studies of tobacco-

control efforts suggest an association between

advertising bans amp decreased tobacco

consumption

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Discourage consumption of sugar-sweetened

beverages

--One longitudinal study of a school-based

intervention among Native-American high school

students showed a substantial reduction in

sugar-sweetened beverages over a 3-year

period

--A RCT of a home-based intervention that

eliminated sugar-sweetened beverages showed

reduction in BMI scores

Recommended Community Strategies Strategies to encourage breastfeeding

Increase support for breastfeeding

--Evidence directly linking environmental

interventions that support breastfeeding with

obesity-related outcomes is lacking

--Epidemiologic studies indicate that breastfeeding

helps prevent pediatric obesity

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Require physical education in schools

--14 studies have demonstrated that school-based

PE was effective in increasing levels of physical

activity and improving physical fitness

--Minimum of 150 minwk in elementary schools

225 minwk in middle schools and high schools

throughout the school year as recommended by

NASPE

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Increase opportunities for extracurricular

physical activity

--Participation in after-school programs increased

studentsrsquo level of physical activity amp improved

obesity-related outcomes (improved CV fitness

reduced body fat)

--2 pilot studies providing extracurricular physical

activity showed increased levels of PA amp

decreased sedentary behavior

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Reduce screen time in public service venues

--A school-based RCT indicated that children who

reduced their television videotape amp video

game use had significant decrease in BMI tricep

skin fold thickness amp waist circumference

compared to controls

--Spending less time watching television is

associated with increased physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Improve access to outdoor recreational

facilities

--Review of 108 studies indicated that access to facilities

and programs for recreation near their homes amp time

spent outdoors correlated positively with increased

physical activity among childrenamp adults

--Perceptions that footpaths are safe for walking was

significantly associated with adults being classified as

physically active at a level sufficient for health benefits

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting

bicycling

--Longitudinal intervention studies have

demonstrated that improving bicycling

infrastructure is associated with increased

frequency of bicycling

--Cross-sectional studies indicated a significant

association between bicycling infrastructure amp

frequency of biking

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting walking

--Reviews of cross-sectional studies of

environmental correlates of physical activity amp

walking generally find a positive association

between infrastructure supportive of walking amp

physical activity

--Identifying amp creating safe routes to school

together with educational components

increased the number of students walking to

school

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Locating schools within easy walking

distance of residential areas

--Community-scale urban design amp land use policies amp

practices including locating schools stores workplaces

amp recreation areas close to residential areas are

effective in facilitating an increase in levels of physical

activity

--Majority of efforts to encourage walking to school involve

improving the routes rather than improving the location

of schools

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Improve access to public transportation

--Insufficient evidence exists to determine

effectiveness of transportation policies in

increasing the level of physical activity or

improving fitness

--1 study indicated that 29 of individuals who

walk to and from public transit achieve at least

30 minutes of daily physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Zone for mixed-use development

--Allows residential commercial institutional amp

other public land uses to be located in close

proximity to one another

--Studies using correlation analyses amp regression

models indicated that mixed land use was

associated with increased walking amp cycling

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance personal safety in areas where

persons are or could be physically active

--Cross-sectional studies have demonstrated a

negative relationship between crime rates andor

perceived safety amp physical activity in

neighborhoods

--Few intervention studies have evaluated the

impact of policies amp practices to improve

personal safety on physical activity

Geospatial Mapping Linking Urban

Environments to Health Risk

Measure association between environmental variables amp health risk factors

Assess relationships between variables at different levels of analysis

Used in conjunction with linear analyses

Our Community Environmental Model

of Obesity

Community Factors

Poverty

Crime

Grocery Quality

Restaurants

Parks

Sidewalks

Fast Food Outlets

Recreational

Facilities

Individual Factors

Dietary Intake

Physical Activity

Genetics

Family History

StressCoping

Eating Disorders

Psychological

Problems

Weight

Status

Chosen Neighborhoods

Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped

We then matched census-block groups within the income groups by population density and percentage of minority representation

One matched block group per income level was randomly selected

Prevalence of Obesity in

Block-Groups

0

5

10

15

20

25

30

35

40

45

50

Ag

e-a

dju

sted

Ob

esit

y P

rev

ale

nce

(

)

High-Income Low-Income

Age-standardized to the 1990 US Census

Density of Environmental Factors in the

Community Contributes to a ldquoToxicrdquo

Obesity Environment

0

2

4

6

8

10

12

14

16

18

Fast-food Convenience Store Bars

Den

sity

10

00

perso

ns

High-Income Low-Income

COMMUNITYrsquoS PERCEPTION OF SAFETY

0

5

10

15

20

25

30

35

40

Daytime Nighttime

Perc

en

t (

) F

eeli

ng

So

mew

hat

Safe

or

Un

safe

Low-Income High-Income

Percent Substandard (or worse) Housing

or Ground Conditions

of Residential Properties

0

10

20

30

Structural Grounds

Perc

en

t (

)

Low-Income High-Income

CONCLUSIONS

These data suggest that the higher

frequency of outlets providing

calorically-dense foods and alcohol may

contribute to greater obesity prevalence

in residents of low-income communities

More research is needed to thoroughly

document environmental determinants

of health and obesity

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

From 1994-1998 HUD randomly assigned

4498 women with children living in public

housing in high-poverty urban census

tracts to one of three groups (1) housing

vouchers redeemable only if they moved

to a low-poverty census tract (2)

unrestricted vouchers or (3) control group

(no vouchers)

Ludwig et al NEJM 201136516

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

10-12 year follow-up showed modest but

potentially important reductions in the

prevalence of extreme obesity amp diabetes in the

group moving from a neighborhood with high

poverty on one of low poverty compared to the

control group

No differences between the group receiving

traditional vouchers amp the control group

ldquoNeighborhoods matterrdquo

Ludwig et al NEJM 201136516

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance traffic safety in areas where

persons are or could be physically active

--Community-scale urban design amp land use policies to

promote physical activity including design components

to improve street lighting infrastructure projects to

increase safety of pedestrian street crossing and use of

traffic calming approaches such as speed humps amp

traffic circles are effective in increasing physical activity

--Both community-scale amp street-scale policies amp practices

are effective in increasing physical activity

Recommended Community Strategies Encourage Communities to Organize for Change

Participate in community coalitions or

partnerships to address obesity

--Little evidence is available to determine the

impact of community coalitions on obesity

prevention

--The presence of anti-smoking community

coalitions has been associated with lower rates

of tobacco consumption

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

$103 million awarded to 61 states and

communities including state amp local government

agencies tribes amp territories amp state amp local non-

profit organizations

To build capacity to implement changes for

community prevention efforts to ensure long-

term success

To implement evidence-based and practice-

based programs to improve health amp wellness

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Priority areas are

Tobacco-free living

Active living and healthy eating

Evidence-based quality clinical and other

preventive health services for prevention

and control of high blood pressure and

high cholesterol

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Applicants proposed specific activities in

line with their chosen priority areas in their

applications

Grantee activities will not be finalized until

plans are negotiated with CDC by early

2012

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Capacity-Building Award

The Confederated Tribes of The Chehalis

Reservation is receiving a $498663 planning

award to build capacity to support healthy

lifestyles among their tribal population of 1500

in Washington State

Work will target tobacco-free living active living

and healthy eating and quality clinical and other

healthy serviceswwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Implementation Award

Austin TX Dept of Health and Human Services

is receiving $1026158 to serve Travis County

(Austin) to expand efforts in tobacco-free living

active living and healthy eating quality clinical

and other preventive services social and

emotional wellness and healthy and safe

physical environmentswwwcdcgov1052011

Building sustainable healthy

communities Bottom line

Obesity is an environmental problem

Despite progress in genetic research public health advances only will occur when we take the environment seriously

Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment

Until we do this we will not make substantial progress in addressing the epidemic of obesity

Poston amp Foreyt Atherosclerosis 1999

Whatrsquos the best approach

Integrate all sectors of society into community

change interventions

Incorporate

Science amp Technology

Education

FamilyCommunity

Healthcare

Arts amp Entertainment

Law amp Politics

Commerce amp Trade

Sectors of Society

Arts amp Entertainm

ent

Commerce amp Trade

Education

FamilyCommunity

Healthcare

Law amp Politics

Science amp Technology

Project FIT rationale design and baseline characteristics of a school- and community-

based intervention to address physical activity and healthy eating among low-income

elementary school children

Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D

Oh HJ Orth J Randall S Mayfield K Holmes D

Source

Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu

Abstract

BACKGROUND

This paper describes Project FIT a collaboration between the public school system local

health systems physicians neighborhood associations businesses faith-based leaders

community agencies and university researchers to develop a multi-faceted approach to

promote physical activity and healthy eating toward the general goal of preventing and

reducing childhood obesity among children in Grand Rapids MI USA

METHODSDESIGN

There are four overall components to Project FIT school community social marketing and

school staff wellness - all that focus on 1) increasing access to safe and affordable physical

activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)

improving the affordability and availability of nutritious food in the neighborhoods surrounding

the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding

nutrition and physical activity among school staff parents and students 4) impacting the

culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging

dialogue among all community partners to leverage existing programs and introduce new

ones

Education

National School Lunch Program

Farmersrsquo Markets

Commerce and Trade

Science amp Technology

WiiFit

X-box

Kinect

Nike run

Health

Blogs

Phone Apps

Arts and Entertainment

Walking School

BusKids used to walk to school all the time Whatley says Now its almost impossible And with childhood obesity rates on the rise Whatley says walking is important because its the easiest way to exercise for a lifetime

FamilyCommunity

Health Care

Results of Lifestyle Interventions for

Weight Loss

ldquoThose who complete weight-loss programs lose approximately 10 of their body weight only to regain two-thirds of it back within one year and almost all of it back within 5 yearsrdquo

Institute of Medicine Weighing the options Criteria for evaluating

weight management programs 1995

Weekly group sessions over 4 ndash 6 months

Mean post-treatment weight reductions of ~ 8-10

Attrition rates are high at 2-yrs (mean = 39 range 20-65)

Attrition rates beyond 2-yrs (mean = 65)

Perri Foreyt amp Anton Preventing Weight

Regain After Weight Loss 2008

Results of Lifestyle Interventions for

Weight Loss

Results of Lifestyle Interventions

Pattern of Weight Regain

Weight regain occurs steadily over 2-5 yrs

Long-term follow-ups of behavioral interventions show a reliable pattern of gradual regaining of lost weight

Long-term losses of ge 5 Kg are sustained in less than 20 of patients in behavioral treatment

Perri Foreyt amp Anton Preventing Weight

Regain After Weight Loss 2008

Results of Lifestyle Interventions

Pattern of Weight Regain

ldquoThe difficulty associated with

maintaining lost weight appears to

be the result of physiological

environmental and psychological

factors that combine to facilitate a

regaining of lost weight and an

abandonment of weight control

effortsrdquo

Perri Foreyt amp Anton 2008

Population-wide prevention of obesity

Small changes in diet and physical activity may make more sense than focusing on large behavioral changes

By cutting 100 calories a day adults can prevent weight gain

Hill et al Science 2003 Hill AJCN 2009

BENEFITS OF MODEST WEIGHT LOSS

ldquoSeveral studies demonstrate that small losseshelliphelp reduce obesity-related co-morbidities and that improvements in these risk factors persist with maintenance of these modest weight lossesrdquo

Institute of Medicine 1995

- Glucose levels - HDL cholesterol levels

- Insulin levels - LDL cholesterol levels

- Glycated hemoglobin - Blood pressure

- Triglyceride levels - Quality of life levels

Stigmatization amp Discrimination

Societal beliefs that weight can be controlled thereby suggestive of character deficits (lack of willpower laziness and emotional problems)

Negative attitudes

ldquoLast safe prejudicerdquo in US society

Rand CSW Macgregor AMC South Med J 1990

DISCRIMINATION

THE PAIN OF OBESITY

Former severely obese patients

100 preferred to be deaf dyslexic

diabetic or have heart disease or bad

acne than to be obese again

Leg amputation was preferred by

915 and blindness by 894

100 preferred to be a normal weight

person rather than a severely obese

multi-millionaire Rand CSW Macgregor AMC Int J Obes 199115577ndash579

Psychosocial Burden of Obesity

Obese individuals often feel misunderstood neglected and rejected

Obese individuals have low employment prospects and are denied educational vocational and advancement opportunities

Significantly poorer quality of life

van Hout GCM van Oudheusden I amp van Heck GL Obes Surg 2004

A Healthy Lifestyle is All About

Balance

Healthy Diet

Healthy Physical Activity

Building Sustainable Healthy

Communities

Healthy Lifestyle

Building Sustainable Healthy

Communities

Healthy Lifestyle

UNFORTUNATELYhellip

Big Texan Steak Ranch

Amarillo Texas

72-oz Steak FREE if eaten within 1 hour

AVERAGE ADULT AMERICAN MAN

Height 5rsquo 8rdquo

Weight 195 lbs

Waist 397 in

BMI 284

CDC 2011

AVERAGE ADULT AMERICAN WOMAN

Height 5rsquo3rdquo

Weight 165 lbs

Waist 370 in

BMI 261

CDC 2011

Miss America

2008

Kirsten Haglund

BMI 1629

Eliana Ramos

Age 18

Height 5rsquo9rdquo

29th OLYMPIAD

BEIJING CHINA

US wrestling team captain Daniel

Cormier (2115 lbs) hospitalized for

kidney failure as result of

dehydration related to cutting weight

(did not compete)

US boxer Gary Russell was found

unconscious 4 days before his

Olympic bout due to cutting weight

(did not compete)

29th OLYMPIAD

BEIJING CHINA

Michael Phelps

8 Gold Medals SwimmingAge 23

Height 6rsquo4rdquo

Weight 195 lbs

BMI 2374

Daily Food Intake 10375 KCAL

(15 PRO 58 CHO 27 FAT)

Exercise 30 hrswk

2005 USDA FOOD PYRAMID

ldquoThe food pyramid

is too complicated

and has too many

messagesrdquo

Robert Post PhD USDA Deputy

Director 2011

2005 USDA FOOD PYRAMID

ldquoItrsquos going to be hard not to do

better than the current pyramid

which basically conveys no

useful informationrdquo

Walter C Willett MD

Chairman Department of Nutrition

Harvard School of Public Health

2011 USDA MY PLATE

ldquoWe are all

bombarded with so

many dietary

messages that it is

hard to find time to

sort through all this

informationrdquo

Michelle Obama 2011

Dietary Guidelines for Americans

2010 Two Primary Concepts

Maintain calorie balance over time to

achieve and maintain a healthy weight

Focus on consuming nutrient-dense foods

and beverages

Dietary Guidelines for Americans 2010

Efficacy-based comparative dietary guidelines

Carb Fat Pro

Mediterranean Diet 45-55 25-35 20

IOM Dietary Ref Intakes 45-65 25-35 15

NCEP-ATPIII 50-60 25-35 15

Am Dietetic Assoc 45-65 20-35 15

PARADOX OF INCREASING OBESITY

PREVALENCE

bull Focus on healthy eating and physical

activity

bull Awareness of dangers of obesity buthellip

bull Obesity prevalence continues to rise

bull Work amp commuting demands

bull Little time to exercise

bull Little time to prepare food

bull Availability of high-fatcalorie foods

Rationale for community-based interventions

bull Increases in obesity prevalence due to genes

bull Increased calories (eg 200 Kcalday

over 10 years)

bull Increased portion sizes (eg 22 oz

steaks and 44 oz sodas)

bull Western diets in developing nations

increase risk of obesity

READINESS TO CHANGE

ldquoHabit is habit and not to be

flung out of the window but

coaxed downstairs a step at a

timerdquo

Mark Twain

Long-Term Weight Maintenance

National Weight Control Registry (N=10000)

Survey of 3000 members who have been in the

Registry for at least 10 years

Starting weight = 224 lbs Average weight loss=69

lbs

At 5 years participants had maintained an average

weight loss=52 lbs

At 10 years participants had maintained an average

weight loss=51 lbs

Thomas Bond Phelan et al TOS 2011

Long-Term Weight Maintenance

Weight Maintainers report that they usually

Track their food intake

Count calories or fat grams

Follow a low-calorie low fat diet (1800 caloriesday

less than 30 of calories from fat

Eat breakfast regularly

Limit the amount they eat out (about 3 timesweek

eat fast food less than onceweek)

Thomas Bond Phelan et al TOS 2011

Long-Term Weight Maintenance

Weight Maintainers report that they usually

Eat similar food regularly

Donrsquot splurge much on holidays amp special occasions

Walk about one hourday

Watch less than 10 hours of TV a week

Weigh themselves at least once a week

Thomas Bond Phelan et al TOS 2011

LONG-TERM WEIGHT MAINTENANCE

Continued consumption of a low-

calorie diet with moderate fat intake

Limited fast food

High levels of physical activity

Phalen et al Obesity 2006 14 710-716

LONG-TERM WEIGHT MAINTENANCE

Daily weighing improved

maintenance of weight loss

particularly when delivered

face to face

Wing et al NEJM 2006 3551563-1571

Most Promising Strategies For

Preventing Weight Regain

Providing multi-component

programs with ongoing

professional contacts

Physical activityexercise

Portion controlmeal replacements

Extending treatment through

weekly or bi-weekly sessions

Pharmacotherapy

Perri Foreyt amp Anton Preventing Weight Regain After Weight Loss 2008

Most Promising Strategies For

Preventing Weight Regain

Extended treatments have shown

promise in promoting adherence to

the behaviors required for the long-

term maintenance of weight loss

Continuous care approach focused

on reasonable long-term objectives

appears appropriate for most

patients

Perri Foreyt amp Anton Preventing Weight Regain After Weight

Loss 2008

An Example of a successful long-term

intervention

The Look AHEAD Study

Does Weight Loss Reduce

Cardiovascular Disease and Death in

Overweight Individuals with Diabetes

bull Action for HEAlth in Diabetes

bull Objective to examine in overweight

persons with Type 2 Diabetes the long-

term effects of an intensive lifestyle

intervention program compared to

diabetes education and support

bull 16 Centers

bull 5145 overweight volunteers with

diabetes

Look AHEAD

Look AHEAD

Primary End Point Composite

bull Cardiovascular death (including fatal

myocardial infarction and stroke)

bull Non-fatal myocardial infarction

bull Non-fatal stroke

Winston-Salem

Baltimore

Philadelphia

New York

Providence

Boston

Clinical Site Coordinating Center

Clinical Sites

Seattle

Los Angeles

San AntonioHouston

Baton Rouge

Minneapolis

Memphis

Birmingham

Pittsburgh

Denver

Phoenix

Look AHEADParticipants

101100Baseline weight (kg)

589586Age (years)

9496Attended 1 year exam

360359Baseline BMI

1514Insulin Users

3737Minority

6059Women

(N=2574)(N=2630)

DSELifestyle

p lt 0004

Look AHEAD

Study Interventions

bull Diabetes support and education - DSE (control group)

bull Lifestyle intervention ndash ILI (treatment group)

Look AHEAD

Lifestyle Intervention

Goals

bull 7 weight loss for the group (10

for individual)

bull 175 minutes of moderate intensity

activity

Look AHEAD

Lifestyle Intervention

bull Diet

ndash ADA NCEP (lt 30 fat lt 10 sat fat

gt15 protein)

ndash 1200-1500 (if weight lt250lbs)

ndash 1500-1800 (if weight gt250lbs)

ndash During first 4 weeks to 4 months portion

control (liquid meal replacements or

structured meal plan)

Look AHEAD

Lifestyle Intervention

bull Physical Activity

ndash unsupervised

ndash 175 minutes moderate intensityweek

ndash 5 daysweek

ndash walking

Weight Loss at 1-Year

-9

ILI 0

-1

-2

-3

-4

-5

-6

-7

-8

DSE

p lt 00001

W

eig

ht

Chan

ge

86

07

The Look AHEAD Research Group Diabetes Care 2007

Reduction in Initial Weight by Gender

N=872

N=1229N=1197

N=830

-12

-10

-8

-6

-4

-2

0

0 2 4 6 8 10 12

Months

R

ed

uctio

n in

In

itia

l W

eig

ht

Men

Women

Plt0001

The Look AHEAD Research Group Diabetes Care 2007

Fitness Change () at 1-Year

0

5

10

15

20

25

Mean

Fitness C

hange

Unadjusted

Plt0001Adjusted for 1 Year

Weight Change Plt0001

58

209

108

159

DSE ILI ILIDSE

The Look AHEAD Research Group Diabetes Care 2007

1-Year Changes in Markers of

Diabetes Control

Markers of Diabetes

Control ILI DSE P-value

Hemoglobin A1c () BL

Hemoglobin A1c () Y1

Y1 ndash Baseline

725

661

-064

729

715

-014

026

lt0001

lt0001

Fasting glucose (mgdl) BL

Fasting glucose (mgdl) Y1

Y1 ndash Baseline

1519

1304

-215

1536

1464

-72

021

lt0001

lt0001

Diabetes medications BL

Diabetes medications Y1

Y1 ndash Baseline

865

786

-78

865

887

22

093

lt0001

lt0001

1-Year Changes in Markers of

Blood Pressure ControlMarkers of Blood Pressure

Control ILI DSE P-value

Systolic BP (mmHg) BL

Systolic BP (mmHg) Y1

Y1 ndash Baseline

1282

1214

-68

1294

1266

-28

026

lt0001

lt0001

Diastolic BP (mmHg) BL

Diastolic BP (mmHg) Y1

Y1 ndash Baseline

699

670

-30

704

686

-18

011

lt0001

lt0001

Antihypertensive medications BL

Antihypertensive medications Y1

Y1 ndash Baseline

753

752

-01

737

759

22

023

054

002

1-Year Changes in Markers of Lipid

Control

Markers of Lipid Control ILI DSE P-value

LDL-cholesterol (mgdl) BL

LDL-cholesterol (mgdl) Y1

Y1 ndash Baseline

1122

1070

-52

1124

1067

-57

078

074

049

HDL-cholesterol (mgdl) BL

HDL-cholesterol (mgdl) Y1

Y1 ndash Baseline

435

469

34

436

449

14

080

lt0001

lt0001

Triglycerides (mgdl) BL

Triglycerides (mgdl) Y1

Y1 ndash Baseline

1828

1525

-303

1800

1654

-146

038

lt0001

lt0001

Lipid lowering medications BL

Lipid lowering medications Y1

Y1 ndash Baseline

494

530

37

484

578

94

052

lt0001

lt0001

1-Year Changes in Percent of Participants

Meeting ADA Goals

ADA Goal ILI DSE P-value

Hemoglobin A1c lt 7 BL

Hemoglobin A1c lt 7 Y1

Y1 ndash Baseline

463

727

264

454

508

54

050

lt0001

lt0001

Blood pressure lt 13080 mmHg BL

Blood pressure lt 13080 mmHg Y1

Y1 ndash Baseline

535

686

151

499

570

70

001

lt0001

lt0001

LDL-cholesterol lt 100 mgdl BL

LDL-cholesterol lt 100 mgdl Y1

Y1 ndash Baseline

371

438

67

369

449

80

087

045

034

All three goals BL

All three goals Y1

Y1 ndash Baseline

108

236

128

95

160

65

013

lt0001

lt0001

Mean Changes in Weight Fitness amp BP

Averaged Over Four Years

DSE

Mean

ILI

Mean

P-value

Weight Loss

( initial wt)

-088 -615 lt 00001

Fitness

( METS)

196 1274 lt00001

HbA1c -009 -036 lt 00001

SBP (mm Hg) -297 -533 lt 00001

DBP (mm Hg) -248 -292 0012

Look AHEAD Research Group Arch Int Med 2010

Mean Changes in Lipid Profile

Averaged Over Four Years

DSE

Mean

ILI

Mean

P-value

HDL (mgdl) 197 367 lt00001

TG (mgdl) -1975 -2556 00006

LDL (mgdl) -1284 -1127 0009

LDL (mgdl)

(Adjusting for

medication use)

-922 -875 042

Look AHEAD Research Group Arch Int Med 2010

Percent () Completing Outcome

Measures at Years 1-4

Intervention Group

(ILI)

Year 1 971

Year 2 949

Year 3 940

Year 4 941

Comparison Group

(DSE)

Year 1 957

Year 2 935

Year 3 938

Year 4 931

Look AHEAD Summary

ILI had significantly greater improvements than DSE in all CVD risk factors averaged across 4 years (except LDL-C)

There may be long-term beneficial effects from this 4-year period in which ILI subjects have been exposed to lower CVD risk factors

Longer follow-ups will determine whether these lowered CVD risk factors can be maintained amp whether lifestyle intervention has positive effects on CVD morbidity amp mortality

Mary J

Female

White

56 years old at start of Look AHEAD

study

Past Medical History Type 2 diabetes

overweight diverticulosis arthritis

sleep apnea back pain

Mary J

bullLong term strugglesbull Helping youngest daughter with

personal issues and children

bull Rotator cuff problems

bull Degenerative disks in back

bull Rheumatoid arthritis

bull Diabetes

bull Physically demanding job

bull Financial struggles

Pounds

Years

82007 grandkids enter pre-school

Catherine L

Female

White

47 years old at start of Look AHEAD

study

Past Medical History Type 2 diabetes

overweight high blood pressure

hypothyroidism back pain

Catherine L

Long term struggles

bull Motherrsquos declining health and death

bull Multiple serious injuries

bull Sudden death of sister

bull Death of step-father

bull Declining economy

bull Children living at home

Pounds

Years

Realistic Management Goals

5-10 weight loss

Health energy and fitness

Well-being and self-esteem

Mood and appearance

Functional and recreational

activity

Key Elements

Focus on health and energy

Food and physical activity diaries

Gradual increase in physical activity

Gradual reduction in dietary fat

No feelings of food deprivation

Social support groups

Recommended Strategies for Building

Sustainable Healthy Communities

Overview from USA

Promote the availability of affordable healthy

food and beverages

Support healthy food and beverage choices

Encourage breastfeeding

Encourage physical activity or limit sedentary

activity among children amp youth

Create safe communities that support physical

activity

Encourage communities to organize for change

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Increase the availability of healthier food and

beverage choices in public service venues (eg

schools city amp county buildings etc)

--Insufficient evidence in school-based programs

--Associations suggest availability amp increased

consumption

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve availability of affordable healthier

food amp beverage choices in public service

venues

--Reducing the cost of healthier foods

increases their purchase

--Providing coupons redeemable for

healthier foods increases their purchase

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve geographic availability of

supermarkets in underserved areas

-- Greater access to nearby supermarkets is

associated with healthier eating behaviors

-- Increasing the number of supermarkets in

underserved neighborhoods increased

real estate values increased economic

activity amp employment amp resulted in lower

food prices

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Provide incentives to food retailers to locate in

andor offer healthier food choices in

underserved areas

-- Presence of retail venues that provide healthier

foods is associated with better nutrition

-- Greater availability of supermarkets was

associated with lower adolescent BMI scores

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Improve availability of mechanisms for

purchasing foods from farms

--Evidence supporting a direct link between

purchasing food from farms amp improved diet is

limited

--Two studies of initiatives to encourage

participation in farmersrsquo market showed

increased intention to eat more fruits amp

vegetables but no direct evidence

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Provide incentives for the production

distribution and procurement of foods from local

farms

--No evidence has been published to link local

food production amp health outcomes

--There is a current study exploring the potential

nutritional amp health benefits of eating locally

grown foods

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Restrict availability of less healthy foods amp

beverages in public service venues

--No peer-reviewed studies examined the impact

designed to restrict availability of less healthy

foods in public service venues

--21 states have policies that restrict the sale of

competitive foods in schools beyond USDA

regulations however no studies have evaluated

the impact of the policies

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Institute smaller portion size options in public

service venues

--Evidence is lacking to demonstrate effectiveness

of population-based interventions aimed at

reducing portion sizes in public service venues

--Evidence from clinical studies in laboratories

demonstrates decreasing portion sizes

decreases energy intake

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Limit advertisements of less healthy foods amp

beverages

--Little evidence is available regarding the impact

of restricting advertising on purchasing amp

consumption of less healthy foods

--Cross-sectional time-series studies of tobacco-

control efforts suggest an association between

advertising bans amp decreased tobacco

consumption

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Discourage consumption of sugar-sweetened

beverages

--One longitudinal study of a school-based

intervention among Native-American high school

students showed a substantial reduction in

sugar-sweetened beverages over a 3-year

period

--A RCT of a home-based intervention that

eliminated sugar-sweetened beverages showed

reduction in BMI scores

Recommended Community Strategies Strategies to encourage breastfeeding

Increase support for breastfeeding

--Evidence directly linking environmental

interventions that support breastfeeding with

obesity-related outcomes is lacking

--Epidemiologic studies indicate that breastfeeding

helps prevent pediatric obesity

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Require physical education in schools

--14 studies have demonstrated that school-based

PE was effective in increasing levels of physical

activity and improving physical fitness

--Minimum of 150 minwk in elementary schools

225 minwk in middle schools and high schools

throughout the school year as recommended by

NASPE

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Increase opportunities for extracurricular

physical activity

--Participation in after-school programs increased

studentsrsquo level of physical activity amp improved

obesity-related outcomes (improved CV fitness

reduced body fat)

--2 pilot studies providing extracurricular physical

activity showed increased levels of PA amp

decreased sedentary behavior

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Reduce screen time in public service venues

--A school-based RCT indicated that children who

reduced their television videotape amp video

game use had significant decrease in BMI tricep

skin fold thickness amp waist circumference

compared to controls

--Spending less time watching television is

associated with increased physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Improve access to outdoor recreational

facilities

--Review of 108 studies indicated that access to facilities

and programs for recreation near their homes amp time

spent outdoors correlated positively with increased

physical activity among childrenamp adults

--Perceptions that footpaths are safe for walking was

significantly associated with adults being classified as

physically active at a level sufficient for health benefits

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting

bicycling

--Longitudinal intervention studies have

demonstrated that improving bicycling

infrastructure is associated with increased

frequency of bicycling

--Cross-sectional studies indicated a significant

association between bicycling infrastructure amp

frequency of biking

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting walking

--Reviews of cross-sectional studies of

environmental correlates of physical activity amp

walking generally find a positive association

between infrastructure supportive of walking amp

physical activity

--Identifying amp creating safe routes to school

together with educational components

increased the number of students walking to

school

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Locating schools within easy walking

distance of residential areas

--Community-scale urban design amp land use policies amp

practices including locating schools stores workplaces

amp recreation areas close to residential areas are

effective in facilitating an increase in levels of physical

activity

--Majority of efforts to encourage walking to school involve

improving the routes rather than improving the location

of schools

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Improve access to public transportation

--Insufficient evidence exists to determine

effectiveness of transportation policies in

increasing the level of physical activity or

improving fitness

--1 study indicated that 29 of individuals who

walk to and from public transit achieve at least

30 minutes of daily physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Zone for mixed-use development

--Allows residential commercial institutional amp

other public land uses to be located in close

proximity to one another

--Studies using correlation analyses amp regression

models indicated that mixed land use was

associated with increased walking amp cycling

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance personal safety in areas where

persons are or could be physically active

--Cross-sectional studies have demonstrated a

negative relationship between crime rates andor

perceived safety amp physical activity in

neighborhoods

--Few intervention studies have evaluated the

impact of policies amp practices to improve

personal safety on physical activity

Geospatial Mapping Linking Urban

Environments to Health Risk

Measure association between environmental variables amp health risk factors

Assess relationships between variables at different levels of analysis

Used in conjunction with linear analyses

Our Community Environmental Model

of Obesity

Community Factors

Poverty

Crime

Grocery Quality

Restaurants

Parks

Sidewalks

Fast Food Outlets

Recreational

Facilities

Individual Factors

Dietary Intake

Physical Activity

Genetics

Family History

StressCoping

Eating Disorders

Psychological

Problems

Weight

Status

Chosen Neighborhoods

Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped

We then matched census-block groups within the income groups by population density and percentage of minority representation

One matched block group per income level was randomly selected

Prevalence of Obesity in

Block-Groups

0

5

10

15

20

25

30

35

40

45

50

Ag

e-a

dju

sted

Ob

esit

y P

rev

ale

nce

(

)

High-Income Low-Income

Age-standardized to the 1990 US Census

Density of Environmental Factors in the

Community Contributes to a ldquoToxicrdquo

Obesity Environment

0

2

4

6

8

10

12

14

16

18

Fast-food Convenience Store Bars

Den

sity

10

00

perso

ns

High-Income Low-Income

COMMUNITYrsquoS PERCEPTION OF SAFETY

0

5

10

15

20

25

30

35

40

Daytime Nighttime

Perc

en

t (

) F

eeli

ng

So

mew

hat

Safe

or

Un

safe

Low-Income High-Income

Percent Substandard (or worse) Housing

or Ground Conditions

of Residential Properties

0

10

20

30

Structural Grounds

Perc

en

t (

)

Low-Income High-Income

CONCLUSIONS

These data suggest that the higher

frequency of outlets providing

calorically-dense foods and alcohol may

contribute to greater obesity prevalence

in residents of low-income communities

More research is needed to thoroughly

document environmental determinants

of health and obesity

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

From 1994-1998 HUD randomly assigned

4498 women with children living in public

housing in high-poverty urban census

tracts to one of three groups (1) housing

vouchers redeemable only if they moved

to a low-poverty census tract (2)

unrestricted vouchers or (3) control group

(no vouchers)

Ludwig et al NEJM 201136516

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

10-12 year follow-up showed modest but

potentially important reductions in the

prevalence of extreme obesity amp diabetes in the

group moving from a neighborhood with high

poverty on one of low poverty compared to the

control group

No differences between the group receiving

traditional vouchers amp the control group

ldquoNeighborhoods matterrdquo

Ludwig et al NEJM 201136516

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance traffic safety in areas where

persons are or could be physically active

--Community-scale urban design amp land use policies to

promote physical activity including design components

to improve street lighting infrastructure projects to

increase safety of pedestrian street crossing and use of

traffic calming approaches such as speed humps amp

traffic circles are effective in increasing physical activity

--Both community-scale amp street-scale policies amp practices

are effective in increasing physical activity

Recommended Community Strategies Encourage Communities to Organize for Change

Participate in community coalitions or

partnerships to address obesity

--Little evidence is available to determine the

impact of community coalitions on obesity

prevention

--The presence of anti-smoking community

coalitions has been associated with lower rates

of tobacco consumption

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

$103 million awarded to 61 states and

communities including state amp local government

agencies tribes amp territories amp state amp local non-

profit organizations

To build capacity to implement changes for

community prevention efforts to ensure long-

term success

To implement evidence-based and practice-

based programs to improve health amp wellness

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Priority areas are

Tobacco-free living

Active living and healthy eating

Evidence-based quality clinical and other

preventive health services for prevention

and control of high blood pressure and

high cholesterol

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Applicants proposed specific activities in

line with their chosen priority areas in their

applications

Grantee activities will not be finalized until

plans are negotiated with CDC by early

2012

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Capacity-Building Award

The Confederated Tribes of The Chehalis

Reservation is receiving a $498663 planning

award to build capacity to support healthy

lifestyles among their tribal population of 1500

in Washington State

Work will target tobacco-free living active living

and healthy eating and quality clinical and other

healthy serviceswwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Implementation Award

Austin TX Dept of Health and Human Services

is receiving $1026158 to serve Travis County

(Austin) to expand efforts in tobacco-free living

active living and healthy eating quality clinical

and other preventive services social and

emotional wellness and healthy and safe

physical environmentswwwcdcgov1052011

Building sustainable healthy

communities Bottom line

Obesity is an environmental problem

Despite progress in genetic research public health advances only will occur when we take the environment seriously

Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment

Until we do this we will not make substantial progress in addressing the epidemic of obesity

Poston amp Foreyt Atherosclerosis 1999

Whatrsquos the best approach

Integrate all sectors of society into community

change interventions

Incorporate

Science amp Technology

Education

FamilyCommunity

Healthcare

Arts amp Entertainment

Law amp Politics

Commerce amp Trade

Sectors of Society

Arts amp Entertainm

ent

Commerce amp Trade

Education

FamilyCommunity

Healthcare

Law amp Politics

Science amp Technology

Project FIT rationale design and baseline characteristics of a school- and community-

based intervention to address physical activity and healthy eating among low-income

elementary school children

Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D

Oh HJ Orth J Randall S Mayfield K Holmes D

Source

Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu

Abstract

BACKGROUND

This paper describes Project FIT a collaboration between the public school system local

health systems physicians neighborhood associations businesses faith-based leaders

community agencies and university researchers to develop a multi-faceted approach to

promote physical activity and healthy eating toward the general goal of preventing and

reducing childhood obesity among children in Grand Rapids MI USA

METHODSDESIGN

There are four overall components to Project FIT school community social marketing and

school staff wellness - all that focus on 1) increasing access to safe and affordable physical

activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)

improving the affordability and availability of nutritious food in the neighborhoods surrounding

the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding

nutrition and physical activity among school staff parents and students 4) impacting the

culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging

dialogue among all community partners to leverage existing programs and introduce new

ones

Farmersrsquo Markets

Commerce and Trade

Science amp Technology

WiiFit

X-box

Kinect

Nike run

Health

Blogs

Phone Apps

Arts and Entertainment

Walking School

BusKids used to walk to school all the time Whatley says Now its almost impossible And with childhood obesity rates on the rise Whatley says walking is important because its the easiest way to exercise for a lifetime

FamilyCommunity

Health Care

Results of Lifestyle Interventions for

Weight Loss

ldquoThose who complete weight-loss programs lose approximately 10 of their body weight only to regain two-thirds of it back within one year and almost all of it back within 5 yearsrdquo

Institute of Medicine Weighing the options Criteria for evaluating

weight management programs 1995

Weekly group sessions over 4 ndash 6 months

Mean post-treatment weight reductions of ~ 8-10

Attrition rates are high at 2-yrs (mean = 39 range 20-65)

Attrition rates beyond 2-yrs (mean = 65)

Perri Foreyt amp Anton Preventing Weight

Regain After Weight Loss 2008

Results of Lifestyle Interventions for

Weight Loss

Results of Lifestyle Interventions

Pattern of Weight Regain

Weight regain occurs steadily over 2-5 yrs

Long-term follow-ups of behavioral interventions show a reliable pattern of gradual regaining of lost weight

Long-term losses of ge 5 Kg are sustained in less than 20 of patients in behavioral treatment

Perri Foreyt amp Anton Preventing Weight

Regain After Weight Loss 2008

Results of Lifestyle Interventions

Pattern of Weight Regain

ldquoThe difficulty associated with

maintaining lost weight appears to

be the result of physiological

environmental and psychological

factors that combine to facilitate a

regaining of lost weight and an

abandonment of weight control

effortsrdquo

Perri Foreyt amp Anton 2008

Population-wide prevention of obesity

Small changes in diet and physical activity may make more sense than focusing on large behavioral changes

By cutting 100 calories a day adults can prevent weight gain

Hill et al Science 2003 Hill AJCN 2009

BENEFITS OF MODEST WEIGHT LOSS

ldquoSeveral studies demonstrate that small losseshelliphelp reduce obesity-related co-morbidities and that improvements in these risk factors persist with maintenance of these modest weight lossesrdquo

Institute of Medicine 1995

- Glucose levels - HDL cholesterol levels

- Insulin levels - LDL cholesterol levels

- Glycated hemoglobin - Blood pressure

- Triglyceride levels - Quality of life levels

Stigmatization amp Discrimination

Societal beliefs that weight can be controlled thereby suggestive of character deficits (lack of willpower laziness and emotional problems)

Negative attitudes

ldquoLast safe prejudicerdquo in US society

Rand CSW Macgregor AMC South Med J 1990

DISCRIMINATION

THE PAIN OF OBESITY

Former severely obese patients

100 preferred to be deaf dyslexic

diabetic or have heart disease or bad

acne than to be obese again

Leg amputation was preferred by

915 and blindness by 894

100 preferred to be a normal weight

person rather than a severely obese

multi-millionaire Rand CSW Macgregor AMC Int J Obes 199115577ndash579

Psychosocial Burden of Obesity

Obese individuals often feel misunderstood neglected and rejected

Obese individuals have low employment prospects and are denied educational vocational and advancement opportunities

Significantly poorer quality of life

van Hout GCM van Oudheusden I amp van Heck GL Obes Surg 2004

A Healthy Lifestyle is All About

Balance

Healthy Diet

Healthy Physical Activity

Building Sustainable Healthy

Communities

Healthy Lifestyle

Building Sustainable Healthy

Communities

Healthy Lifestyle

UNFORTUNATELYhellip

Big Texan Steak Ranch

Amarillo Texas

72-oz Steak FREE if eaten within 1 hour

AVERAGE ADULT AMERICAN MAN

Height 5rsquo 8rdquo

Weight 195 lbs

Waist 397 in

BMI 284

CDC 2011

AVERAGE ADULT AMERICAN WOMAN

Height 5rsquo3rdquo

Weight 165 lbs

Waist 370 in

BMI 261

CDC 2011

Miss America

2008

Kirsten Haglund

BMI 1629

Eliana Ramos

Age 18

Height 5rsquo9rdquo

29th OLYMPIAD

BEIJING CHINA

US wrestling team captain Daniel

Cormier (2115 lbs) hospitalized for

kidney failure as result of

dehydration related to cutting weight

(did not compete)

US boxer Gary Russell was found

unconscious 4 days before his

Olympic bout due to cutting weight

(did not compete)

29th OLYMPIAD

BEIJING CHINA

Michael Phelps

8 Gold Medals SwimmingAge 23

Height 6rsquo4rdquo

Weight 195 lbs

BMI 2374

Daily Food Intake 10375 KCAL

(15 PRO 58 CHO 27 FAT)

Exercise 30 hrswk

2005 USDA FOOD PYRAMID

ldquoThe food pyramid

is too complicated

and has too many

messagesrdquo

Robert Post PhD USDA Deputy

Director 2011

2005 USDA FOOD PYRAMID

ldquoItrsquos going to be hard not to do

better than the current pyramid

which basically conveys no

useful informationrdquo

Walter C Willett MD

Chairman Department of Nutrition

Harvard School of Public Health

2011 USDA MY PLATE

ldquoWe are all

bombarded with so

many dietary

messages that it is

hard to find time to

sort through all this

informationrdquo

Michelle Obama 2011

Dietary Guidelines for Americans

2010 Two Primary Concepts

Maintain calorie balance over time to

achieve and maintain a healthy weight

Focus on consuming nutrient-dense foods

and beverages

Dietary Guidelines for Americans 2010

Efficacy-based comparative dietary guidelines

Carb Fat Pro

Mediterranean Diet 45-55 25-35 20

IOM Dietary Ref Intakes 45-65 25-35 15

NCEP-ATPIII 50-60 25-35 15

Am Dietetic Assoc 45-65 20-35 15

PARADOX OF INCREASING OBESITY

PREVALENCE

bull Focus on healthy eating and physical

activity

bull Awareness of dangers of obesity buthellip

bull Obesity prevalence continues to rise

bull Work amp commuting demands

bull Little time to exercise

bull Little time to prepare food

bull Availability of high-fatcalorie foods

Rationale for community-based interventions

bull Increases in obesity prevalence due to genes

bull Increased calories (eg 200 Kcalday

over 10 years)

bull Increased portion sizes (eg 22 oz

steaks and 44 oz sodas)

bull Western diets in developing nations

increase risk of obesity

READINESS TO CHANGE

ldquoHabit is habit and not to be

flung out of the window but

coaxed downstairs a step at a

timerdquo

Mark Twain

Long-Term Weight Maintenance

National Weight Control Registry (N=10000)

Survey of 3000 members who have been in the

Registry for at least 10 years

Starting weight = 224 lbs Average weight loss=69

lbs

At 5 years participants had maintained an average

weight loss=52 lbs

At 10 years participants had maintained an average

weight loss=51 lbs

Thomas Bond Phelan et al TOS 2011

Long-Term Weight Maintenance

Weight Maintainers report that they usually

Track their food intake

Count calories or fat grams

Follow a low-calorie low fat diet (1800 caloriesday

less than 30 of calories from fat

Eat breakfast regularly

Limit the amount they eat out (about 3 timesweek

eat fast food less than onceweek)

Thomas Bond Phelan et al TOS 2011

Long-Term Weight Maintenance

Weight Maintainers report that they usually

Eat similar food regularly

Donrsquot splurge much on holidays amp special occasions

Walk about one hourday

Watch less than 10 hours of TV a week

Weigh themselves at least once a week

Thomas Bond Phelan et al TOS 2011

LONG-TERM WEIGHT MAINTENANCE

Continued consumption of a low-

calorie diet with moderate fat intake

Limited fast food

High levels of physical activity

Phalen et al Obesity 2006 14 710-716

LONG-TERM WEIGHT MAINTENANCE

Daily weighing improved

maintenance of weight loss

particularly when delivered

face to face

Wing et al NEJM 2006 3551563-1571

Most Promising Strategies For

Preventing Weight Regain

Providing multi-component

programs with ongoing

professional contacts

Physical activityexercise

Portion controlmeal replacements

Extending treatment through

weekly or bi-weekly sessions

Pharmacotherapy

Perri Foreyt amp Anton Preventing Weight Regain After Weight Loss 2008

Most Promising Strategies For

Preventing Weight Regain

Extended treatments have shown

promise in promoting adherence to

the behaviors required for the long-

term maintenance of weight loss

Continuous care approach focused

on reasonable long-term objectives

appears appropriate for most

patients

Perri Foreyt amp Anton Preventing Weight Regain After Weight

Loss 2008

An Example of a successful long-term

intervention

The Look AHEAD Study

Does Weight Loss Reduce

Cardiovascular Disease and Death in

Overweight Individuals with Diabetes

bull Action for HEAlth in Diabetes

bull Objective to examine in overweight

persons with Type 2 Diabetes the long-

term effects of an intensive lifestyle

intervention program compared to

diabetes education and support

bull 16 Centers

bull 5145 overweight volunteers with

diabetes

Look AHEAD

Look AHEAD

Primary End Point Composite

bull Cardiovascular death (including fatal

myocardial infarction and stroke)

bull Non-fatal myocardial infarction

bull Non-fatal stroke

Winston-Salem

Baltimore

Philadelphia

New York

Providence

Boston

Clinical Site Coordinating Center

Clinical Sites

Seattle

Los Angeles

San AntonioHouston

Baton Rouge

Minneapolis

Memphis

Birmingham

Pittsburgh

Denver

Phoenix

Look AHEADParticipants

101100Baseline weight (kg)

589586Age (years)

9496Attended 1 year exam

360359Baseline BMI

1514Insulin Users

3737Minority

6059Women

(N=2574)(N=2630)

DSELifestyle

p lt 0004

Look AHEAD

Study Interventions

bull Diabetes support and education - DSE (control group)

bull Lifestyle intervention ndash ILI (treatment group)

Look AHEAD

Lifestyle Intervention

Goals

bull 7 weight loss for the group (10

for individual)

bull 175 minutes of moderate intensity

activity

Look AHEAD

Lifestyle Intervention

bull Diet

ndash ADA NCEP (lt 30 fat lt 10 sat fat

gt15 protein)

ndash 1200-1500 (if weight lt250lbs)

ndash 1500-1800 (if weight gt250lbs)

ndash During first 4 weeks to 4 months portion

control (liquid meal replacements or

structured meal plan)

Look AHEAD

Lifestyle Intervention

bull Physical Activity

ndash unsupervised

ndash 175 minutes moderate intensityweek

ndash 5 daysweek

ndash walking

Weight Loss at 1-Year

-9

ILI 0

-1

-2

-3

-4

-5

-6

-7

-8

DSE

p lt 00001

W

eig

ht

Chan

ge

86

07

The Look AHEAD Research Group Diabetes Care 2007

Reduction in Initial Weight by Gender

N=872

N=1229N=1197

N=830

-12

-10

-8

-6

-4

-2

0

0 2 4 6 8 10 12

Months

R

ed

uctio

n in

In

itia

l W

eig

ht

Men

Women

Plt0001

The Look AHEAD Research Group Diabetes Care 2007

Fitness Change () at 1-Year

0

5

10

15

20

25

Mean

Fitness C

hange

Unadjusted

Plt0001Adjusted for 1 Year

Weight Change Plt0001

58

209

108

159

DSE ILI ILIDSE

The Look AHEAD Research Group Diabetes Care 2007

1-Year Changes in Markers of

Diabetes Control

Markers of Diabetes

Control ILI DSE P-value

Hemoglobin A1c () BL

Hemoglobin A1c () Y1

Y1 ndash Baseline

725

661

-064

729

715

-014

026

lt0001

lt0001

Fasting glucose (mgdl) BL

Fasting glucose (mgdl) Y1

Y1 ndash Baseline

1519

1304

-215

1536

1464

-72

021

lt0001

lt0001

Diabetes medications BL

Diabetes medications Y1

Y1 ndash Baseline

865

786

-78

865

887

22

093

lt0001

lt0001

1-Year Changes in Markers of

Blood Pressure ControlMarkers of Blood Pressure

Control ILI DSE P-value

Systolic BP (mmHg) BL

Systolic BP (mmHg) Y1

Y1 ndash Baseline

1282

1214

-68

1294

1266

-28

026

lt0001

lt0001

Diastolic BP (mmHg) BL

Diastolic BP (mmHg) Y1

Y1 ndash Baseline

699

670

-30

704

686

-18

011

lt0001

lt0001

Antihypertensive medications BL

Antihypertensive medications Y1

Y1 ndash Baseline

753

752

-01

737

759

22

023

054

002

1-Year Changes in Markers of Lipid

Control

Markers of Lipid Control ILI DSE P-value

LDL-cholesterol (mgdl) BL

LDL-cholesterol (mgdl) Y1

Y1 ndash Baseline

1122

1070

-52

1124

1067

-57

078

074

049

HDL-cholesterol (mgdl) BL

HDL-cholesterol (mgdl) Y1

Y1 ndash Baseline

435

469

34

436

449

14

080

lt0001

lt0001

Triglycerides (mgdl) BL

Triglycerides (mgdl) Y1

Y1 ndash Baseline

1828

1525

-303

1800

1654

-146

038

lt0001

lt0001

Lipid lowering medications BL

Lipid lowering medications Y1

Y1 ndash Baseline

494

530

37

484

578

94

052

lt0001

lt0001

1-Year Changes in Percent of Participants

Meeting ADA Goals

ADA Goal ILI DSE P-value

Hemoglobin A1c lt 7 BL

Hemoglobin A1c lt 7 Y1

Y1 ndash Baseline

463

727

264

454

508

54

050

lt0001

lt0001

Blood pressure lt 13080 mmHg BL

Blood pressure lt 13080 mmHg Y1

Y1 ndash Baseline

535

686

151

499

570

70

001

lt0001

lt0001

LDL-cholesterol lt 100 mgdl BL

LDL-cholesterol lt 100 mgdl Y1

Y1 ndash Baseline

371

438

67

369

449

80

087

045

034

All three goals BL

All three goals Y1

Y1 ndash Baseline

108

236

128

95

160

65

013

lt0001

lt0001

Mean Changes in Weight Fitness amp BP

Averaged Over Four Years

DSE

Mean

ILI

Mean

P-value

Weight Loss

( initial wt)

-088 -615 lt 00001

Fitness

( METS)

196 1274 lt00001

HbA1c -009 -036 lt 00001

SBP (mm Hg) -297 -533 lt 00001

DBP (mm Hg) -248 -292 0012

Look AHEAD Research Group Arch Int Med 2010

Mean Changes in Lipid Profile

Averaged Over Four Years

DSE

Mean

ILI

Mean

P-value

HDL (mgdl) 197 367 lt00001

TG (mgdl) -1975 -2556 00006

LDL (mgdl) -1284 -1127 0009

LDL (mgdl)

(Adjusting for

medication use)

-922 -875 042

Look AHEAD Research Group Arch Int Med 2010

Percent () Completing Outcome

Measures at Years 1-4

Intervention Group

(ILI)

Year 1 971

Year 2 949

Year 3 940

Year 4 941

Comparison Group

(DSE)

Year 1 957

Year 2 935

Year 3 938

Year 4 931

Look AHEAD Summary

ILI had significantly greater improvements than DSE in all CVD risk factors averaged across 4 years (except LDL-C)

There may be long-term beneficial effects from this 4-year period in which ILI subjects have been exposed to lower CVD risk factors

Longer follow-ups will determine whether these lowered CVD risk factors can be maintained amp whether lifestyle intervention has positive effects on CVD morbidity amp mortality

Mary J

Female

White

56 years old at start of Look AHEAD

study

Past Medical History Type 2 diabetes

overweight diverticulosis arthritis

sleep apnea back pain

Mary J

bullLong term strugglesbull Helping youngest daughter with

personal issues and children

bull Rotator cuff problems

bull Degenerative disks in back

bull Rheumatoid arthritis

bull Diabetes

bull Physically demanding job

bull Financial struggles

Pounds

Years

82007 grandkids enter pre-school

Catherine L

Female

White

47 years old at start of Look AHEAD

study

Past Medical History Type 2 diabetes

overweight high blood pressure

hypothyroidism back pain

Catherine L

Long term struggles

bull Motherrsquos declining health and death

bull Multiple serious injuries

bull Sudden death of sister

bull Death of step-father

bull Declining economy

bull Children living at home

Pounds

Years

Realistic Management Goals

5-10 weight loss

Health energy and fitness

Well-being and self-esteem

Mood and appearance

Functional and recreational

activity

Key Elements

Focus on health and energy

Food and physical activity diaries

Gradual increase in physical activity

Gradual reduction in dietary fat

No feelings of food deprivation

Social support groups

Recommended Strategies for Building

Sustainable Healthy Communities

Overview from USA

Promote the availability of affordable healthy

food and beverages

Support healthy food and beverage choices

Encourage breastfeeding

Encourage physical activity or limit sedentary

activity among children amp youth

Create safe communities that support physical

activity

Encourage communities to organize for change

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Increase the availability of healthier food and

beverage choices in public service venues (eg

schools city amp county buildings etc)

--Insufficient evidence in school-based programs

--Associations suggest availability amp increased

consumption

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve availability of affordable healthier

food amp beverage choices in public service

venues

--Reducing the cost of healthier foods

increases their purchase

--Providing coupons redeemable for

healthier foods increases their purchase

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve geographic availability of

supermarkets in underserved areas

-- Greater access to nearby supermarkets is

associated with healthier eating behaviors

-- Increasing the number of supermarkets in

underserved neighborhoods increased

real estate values increased economic

activity amp employment amp resulted in lower

food prices

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Provide incentives to food retailers to locate in

andor offer healthier food choices in

underserved areas

-- Presence of retail venues that provide healthier

foods is associated with better nutrition

-- Greater availability of supermarkets was

associated with lower adolescent BMI scores

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Improve availability of mechanisms for

purchasing foods from farms

--Evidence supporting a direct link between

purchasing food from farms amp improved diet is

limited

--Two studies of initiatives to encourage

participation in farmersrsquo market showed

increased intention to eat more fruits amp

vegetables but no direct evidence

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Provide incentives for the production

distribution and procurement of foods from local

farms

--No evidence has been published to link local

food production amp health outcomes

--There is a current study exploring the potential

nutritional amp health benefits of eating locally

grown foods

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Restrict availability of less healthy foods amp

beverages in public service venues

--No peer-reviewed studies examined the impact

designed to restrict availability of less healthy

foods in public service venues

--21 states have policies that restrict the sale of

competitive foods in schools beyond USDA

regulations however no studies have evaluated

the impact of the policies

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Institute smaller portion size options in public

service venues

--Evidence is lacking to demonstrate effectiveness

of population-based interventions aimed at

reducing portion sizes in public service venues

--Evidence from clinical studies in laboratories

demonstrates decreasing portion sizes

decreases energy intake

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Limit advertisements of less healthy foods amp

beverages

--Little evidence is available regarding the impact

of restricting advertising on purchasing amp

consumption of less healthy foods

--Cross-sectional time-series studies of tobacco-

control efforts suggest an association between

advertising bans amp decreased tobacco

consumption

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Discourage consumption of sugar-sweetened

beverages

--One longitudinal study of a school-based

intervention among Native-American high school

students showed a substantial reduction in

sugar-sweetened beverages over a 3-year

period

--A RCT of a home-based intervention that

eliminated sugar-sweetened beverages showed

reduction in BMI scores

Recommended Community Strategies Strategies to encourage breastfeeding

Increase support for breastfeeding

--Evidence directly linking environmental

interventions that support breastfeeding with

obesity-related outcomes is lacking

--Epidemiologic studies indicate that breastfeeding

helps prevent pediatric obesity

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Require physical education in schools

--14 studies have demonstrated that school-based

PE was effective in increasing levels of physical

activity and improving physical fitness

--Minimum of 150 minwk in elementary schools

225 minwk in middle schools and high schools

throughout the school year as recommended by

NASPE

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Increase opportunities for extracurricular

physical activity

--Participation in after-school programs increased

studentsrsquo level of physical activity amp improved

obesity-related outcomes (improved CV fitness

reduced body fat)

--2 pilot studies providing extracurricular physical

activity showed increased levels of PA amp

decreased sedentary behavior

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Reduce screen time in public service venues

--A school-based RCT indicated that children who

reduced their television videotape amp video

game use had significant decrease in BMI tricep

skin fold thickness amp waist circumference

compared to controls

--Spending less time watching television is

associated with increased physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Improve access to outdoor recreational

facilities

--Review of 108 studies indicated that access to facilities

and programs for recreation near their homes amp time

spent outdoors correlated positively with increased

physical activity among childrenamp adults

--Perceptions that footpaths are safe for walking was

significantly associated with adults being classified as

physically active at a level sufficient for health benefits

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting

bicycling

--Longitudinal intervention studies have

demonstrated that improving bicycling

infrastructure is associated with increased

frequency of bicycling

--Cross-sectional studies indicated a significant

association between bicycling infrastructure amp

frequency of biking

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting walking

--Reviews of cross-sectional studies of

environmental correlates of physical activity amp

walking generally find a positive association

between infrastructure supportive of walking amp

physical activity

--Identifying amp creating safe routes to school

together with educational components

increased the number of students walking to

school

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Locating schools within easy walking

distance of residential areas

--Community-scale urban design amp land use policies amp

practices including locating schools stores workplaces

amp recreation areas close to residential areas are

effective in facilitating an increase in levels of physical

activity

--Majority of efforts to encourage walking to school involve

improving the routes rather than improving the location

of schools

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Improve access to public transportation

--Insufficient evidence exists to determine

effectiveness of transportation policies in

increasing the level of physical activity or

improving fitness

--1 study indicated that 29 of individuals who

walk to and from public transit achieve at least

30 minutes of daily physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Zone for mixed-use development

--Allows residential commercial institutional amp

other public land uses to be located in close

proximity to one another

--Studies using correlation analyses amp regression

models indicated that mixed land use was

associated with increased walking amp cycling

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance personal safety in areas where

persons are or could be physically active

--Cross-sectional studies have demonstrated a

negative relationship between crime rates andor

perceived safety amp physical activity in

neighborhoods

--Few intervention studies have evaluated the

impact of policies amp practices to improve

personal safety on physical activity

Geospatial Mapping Linking Urban

Environments to Health Risk

Measure association between environmental variables amp health risk factors

Assess relationships between variables at different levels of analysis

Used in conjunction with linear analyses

Our Community Environmental Model

of Obesity

Community Factors

Poverty

Crime

Grocery Quality

Restaurants

Parks

Sidewalks

Fast Food Outlets

Recreational

Facilities

Individual Factors

Dietary Intake

Physical Activity

Genetics

Family History

StressCoping

Eating Disorders

Psychological

Problems

Weight

Status

Chosen Neighborhoods

Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped

We then matched census-block groups within the income groups by population density and percentage of minority representation

One matched block group per income level was randomly selected

Prevalence of Obesity in

Block-Groups

0

5

10

15

20

25

30

35

40

45

50

Ag

e-a

dju

sted

Ob

esit

y P

rev

ale

nce

(

)

High-Income Low-Income

Age-standardized to the 1990 US Census

Density of Environmental Factors in the

Community Contributes to a ldquoToxicrdquo

Obesity Environment

0

2

4

6

8

10

12

14

16

18

Fast-food Convenience Store Bars

Den

sity

10

00

perso

ns

High-Income Low-Income

COMMUNITYrsquoS PERCEPTION OF SAFETY

0

5

10

15

20

25

30

35

40

Daytime Nighttime

Perc

en

t (

) F

eeli

ng

So

mew

hat

Safe

or

Un

safe

Low-Income High-Income

Percent Substandard (or worse) Housing

or Ground Conditions

of Residential Properties

0

10

20

30

Structural Grounds

Perc

en

t (

)

Low-Income High-Income

CONCLUSIONS

These data suggest that the higher

frequency of outlets providing

calorically-dense foods and alcohol may

contribute to greater obesity prevalence

in residents of low-income communities

More research is needed to thoroughly

document environmental determinants

of health and obesity

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

From 1994-1998 HUD randomly assigned

4498 women with children living in public

housing in high-poverty urban census

tracts to one of three groups (1) housing

vouchers redeemable only if they moved

to a low-poverty census tract (2)

unrestricted vouchers or (3) control group

(no vouchers)

Ludwig et al NEJM 201136516

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

10-12 year follow-up showed modest but

potentially important reductions in the

prevalence of extreme obesity amp diabetes in the

group moving from a neighborhood with high

poverty on one of low poverty compared to the

control group

No differences between the group receiving

traditional vouchers amp the control group

ldquoNeighborhoods matterrdquo

Ludwig et al NEJM 201136516

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance traffic safety in areas where

persons are or could be physically active

--Community-scale urban design amp land use policies to

promote physical activity including design components

to improve street lighting infrastructure projects to

increase safety of pedestrian street crossing and use of

traffic calming approaches such as speed humps amp

traffic circles are effective in increasing physical activity

--Both community-scale amp street-scale policies amp practices

are effective in increasing physical activity

Recommended Community Strategies Encourage Communities to Organize for Change

Participate in community coalitions or

partnerships to address obesity

--Little evidence is available to determine the

impact of community coalitions on obesity

prevention

--The presence of anti-smoking community

coalitions has been associated with lower rates

of tobacco consumption

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

$103 million awarded to 61 states and

communities including state amp local government

agencies tribes amp territories amp state amp local non-

profit organizations

To build capacity to implement changes for

community prevention efforts to ensure long-

term success

To implement evidence-based and practice-

based programs to improve health amp wellness

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Priority areas are

Tobacco-free living

Active living and healthy eating

Evidence-based quality clinical and other

preventive health services for prevention

and control of high blood pressure and

high cholesterol

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Applicants proposed specific activities in

line with their chosen priority areas in their

applications

Grantee activities will not be finalized until

plans are negotiated with CDC by early

2012

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Capacity-Building Award

The Confederated Tribes of The Chehalis

Reservation is receiving a $498663 planning

award to build capacity to support healthy

lifestyles among their tribal population of 1500

in Washington State

Work will target tobacco-free living active living

and healthy eating and quality clinical and other

healthy serviceswwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Implementation Award

Austin TX Dept of Health and Human Services

is receiving $1026158 to serve Travis County

(Austin) to expand efforts in tobacco-free living

active living and healthy eating quality clinical

and other preventive services social and

emotional wellness and healthy and safe

physical environmentswwwcdcgov1052011

Building sustainable healthy

communities Bottom line

Obesity is an environmental problem

Despite progress in genetic research public health advances only will occur when we take the environment seriously

Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment

Until we do this we will not make substantial progress in addressing the epidemic of obesity

Poston amp Foreyt Atherosclerosis 1999

Whatrsquos the best approach

Integrate all sectors of society into community

change interventions

Incorporate

Science amp Technology

Education

FamilyCommunity

Healthcare

Arts amp Entertainment

Law amp Politics

Commerce amp Trade

Sectors of Society

Arts amp Entertainm

ent

Commerce amp Trade

Education

FamilyCommunity

Healthcare

Law amp Politics

Science amp Technology

Project FIT rationale design and baseline characteristics of a school- and community-

based intervention to address physical activity and healthy eating among low-income

elementary school children

Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D

Oh HJ Orth J Randall S Mayfield K Holmes D

Source

Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu

Abstract

BACKGROUND

This paper describes Project FIT a collaboration between the public school system local

health systems physicians neighborhood associations businesses faith-based leaders

community agencies and university researchers to develop a multi-faceted approach to

promote physical activity and healthy eating toward the general goal of preventing and

reducing childhood obesity among children in Grand Rapids MI USA

METHODSDESIGN

There are four overall components to Project FIT school community social marketing and

school staff wellness - all that focus on 1) increasing access to safe and affordable physical

activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)

improving the affordability and availability of nutritious food in the neighborhoods surrounding

the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding

nutrition and physical activity among school staff parents and students 4) impacting the

culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging

dialogue among all community partners to leverage existing programs and introduce new

ones

Science amp Technology

WiiFit

X-box

Kinect

Nike run

Health

Blogs

Phone Apps

Arts and Entertainment

Walking School

BusKids used to walk to school all the time Whatley says Now its almost impossible And with childhood obesity rates on the rise Whatley says walking is important because its the easiest way to exercise for a lifetime

FamilyCommunity

Health Care

Results of Lifestyle Interventions for

Weight Loss

ldquoThose who complete weight-loss programs lose approximately 10 of their body weight only to regain two-thirds of it back within one year and almost all of it back within 5 yearsrdquo

Institute of Medicine Weighing the options Criteria for evaluating

weight management programs 1995

Weekly group sessions over 4 ndash 6 months

Mean post-treatment weight reductions of ~ 8-10

Attrition rates are high at 2-yrs (mean = 39 range 20-65)

Attrition rates beyond 2-yrs (mean = 65)

Perri Foreyt amp Anton Preventing Weight

Regain After Weight Loss 2008

Results of Lifestyle Interventions for

Weight Loss

Results of Lifestyle Interventions

Pattern of Weight Regain

Weight regain occurs steadily over 2-5 yrs

Long-term follow-ups of behavioral interventions show a reliable pattern of gradual regaining of lost weight

Long-term losses of ge 5 Kg are sustained in less than 20 of patients in behavioral treatment

Perri Foreyt amp Anton Preventing Weight

Regain After Weight Loss 2008

Results of Lifestyle Interventions

Pattern of Weight Regain

ldquoThe difficulty associated with

maintaining lost weight appears to

be the result of physiological

environmental and psychological

factors that combine to facilitate a

regaining of lost weight and an

abandonment of weight control

effortsrdquo

Perri Foreyt amp Anton 2008

Population-wide prevention of obesity

Small changes in diet and physical activity may make more sense than focusing on large behavioral changes

By cutting 100 calories a day adults can prevent weight gain

Hill et al Science 2003 Hill AJCN 2009

BENEFITS OF MODEST WEIGHT LOSS

ldquoSeveral studies demonstrate that small losseshelliphelp reduce obesity-related co-morbidities and that improvements in these risk factors persist with maintenance of these modest weight lossesrdquo

Institute of Medicine 1995

- Glucose levels - HDL cholesterol levels

- Insulin levels - LDL cholesterol levels

- Glycated hemoglobin - Blood pressure

- Triglyceride levels - Quality of life levels

Stigmatization amp Discrimination

Societal beliefs that weight can be controlled thereby suggestive of character deficits (lack of willpower laziness and emotional problems)

Negative attitudes

ldquoLast safe prejudicerdquo in US society

Rand CSW Macgregor AMC South Med J 1990

DISCRIMINATION

THE PAIN OF OBESITY

Former severely obese patients

100 preferred to be deaf dyslexic

diabetic or have heart disease or bad

acne than to be obese again

Leg amputation was preferred by

915 and blindness by 894

100 preferred to be a normal weight

person rather than a severely obese

multi-millionaire Rand CSW Macgregor AMC Int J Obes 199115577ndash579

Psychosocial Burden of Obesity

Obese individuals often feel misunderstood neglected and rejected

Obese individuals have low employment prospects and are denied educational vocational and advancement opportunities

Significantly poorer quality of life

van Hout GCM van Oudheusden I amp van Heck GL Obes Surg 2004

A Healthy Lifestyle is All About

Balance

Healthy Diet

Healthy Physical Activity

Building Sustainable Healthy

Communities

Healthy Lifestyle

Building Sustainable Healthy

Communities

Healthy Lifestyle

UNFORTUNATELYhellip

Big Texan Steak Ranch

Amarillo Texas

72-oz Steak FREE if eaten within 1 hour

AVERAGE ADULT AMERICAN MAN

Height 5rsquo 8rdquo

Weight 195 lbs

Waist 397 in

BMI 284

CDC 2011

AVERAGE ADULT AMERICAN WOMAN

Height 5rsquo3rdquo

Weight 165 lbs

Waist 370 in

BMI 261

CDC 2011

Miss America

2008

Kirsten Haglund

BMI 1629

Eliana Ramos

Age 18

Height 5rsquo9rdquo

29th OLYMPIAD

BEIJING CHINA

US wrestling team captain Daniel

Cormier (2115 lbs) hospitalized for

kidney failure as result of

dehydration related to cutting weight

(did not compete)

US boxer Gary Russell was found

unconscious 4 days before his

Olympic bout due to cutting weight

(did not compete)

29th OLYMPIAD

BEIJING CHINA

Michael Phelps

8 Gold Medals SwimmingAge 23

Height 6rsquo4rdquo

Weight 195 lbs

BMI 2374

Daily Food Intake 10375 KCAL

(15 PRO 58 CHO 27 FAT)

Exercise 30 hrswk

2005 USDA FOOD PYRAMID

ldquoThe food pyramid

is too complicated

and has too many

messagesrdquo

Robert Post PhD USDA Deputy

Director 2011

2005 USDA FOOD PYRAMID

ldquoItrsquos going to be hard not to do

better than the current pyramid

which basically conveys no

useful informationrdquo

Walter C Willett MD

Chairman Department of Nutrition

Harvard School of Public Health

2011 USDA MY PLATE

ldquoWe are all

bombarded with so

many dietary

messages that it is

hard to find time to

sort through all this

informationrdquo

Michelle Obama 2011

Dietary Guidelines for Americans

2010 Two Primary Concepts

Maintain calorie balance over time to

achieve and maintain a healthy weight

Focus on consuming nutrient-dense foods

and beverages

Dietary Guidelines for Americans 2010

Efficacy-based comparative dietary guidelines

Carb Fat Pro

Mediterranean Diet 45-55 25-35 20

IOM Dietary Ref Intakes 45-65 25-35 15

NCEP-ATPIII 50-60 25-35 15

Am Dietetic Assoc 45-65 20-35 15

PARADOX OF INCREASING OBESITY

PREVALENCE

bull Focus on healthy eating and physical

activity

bull Awareness of dangers of obesity buthellip

bull Obesity prevalence continues to rise

bull Work amp commuting demands

bull Little time to exercise

bull Little time to prepare food

bull Availability of high-fatcalorie foods

Rationale for community-based interventions

bull Increases in obesity prevalence due to genes

bull Increased calories (eg 200 Kcalday

over 10 years)

bull Increased portion sizes (eg 22 oz

steaks and 44 oz sodas)

bull Western diets in developing nations

increase risk of obesity

READINESS TO CHANGE

ldquoHabit is habit and not to be

flung out of the window but

coaxed downstairs a step at a

timerdquo

Mark Twain

Long-Term Weight Maintenance

National Weight Control Registry (N=10000)

Survey of 3000 members who have been in the

Registry for at least 10 years

Starting weight = 224 lbs Average weight loss=69

lbs

At 5 years participants had maintained an average

weight loss=52 lbs

At 10 years participants had maintained an average

weight loss=51 lbs

Thomas Bond Phelan et al TOS 2011

Long-Term Weight Maintenance

Weight Maintainers report that they usually

Track their food intake

Count calories or fat grams

Follow a low-calorie low fat diet (1800 caloriesday

less than 30 of calories from fat

Eat breakfast regularly

Limit the amount they eat out (about 3 timesweek

eat fast food less than onceweek)

Thomas Bond Phelan et al TOS 2011

Long-Term Weight Maintenance

Weight Maintainers report that they usually

Eat similar food regularly

Donrsquot splurge much on holidays amp special occasions

Walk about one hourday

Watch less than 10 hours of TV a week

Weigh themselves at least once a week

Thomas Bond Phelan et al TOS 2011

LONG-TERM WEIGHT MAINTENANCE

Continued consumption of a low-

calorie diet with moderate fat intake

Limited fast food

High levels of physical activity

Phalen et al Obesity 2006 14 710-716

LONG-TERM WEIGHT MAINTENANCE

Daily weighing improved

maintenance of weight loss

particularly when delivered

face to face

Wing et al NEJM 2006 3551563-1571

Most Promising Strategies For

Preventing Weight Regain

Providing multi-component

programs with ongoing

professional contacts

Physical activityexercise

Portion controlmeal replacements

Extending treatment through

weekly or bi-weekly sessions

Pharmacotherapy

Perri Foreyt amp Anton Preventing Weight Regain After Weight Loss 2008

Most Promising Strategies For

Preventing Weight Regain

Extended treatments have shown

promise in promoting adherence to

the behaviors required for the long-

term maintenance of weight loss

Continuous care approach focused

on reasonable long-term objectives

appears appropriate for most

patients

Perri Foreyt amp Anton Preventing Weight Regain After Weight

Loss 2008

An Example of a successful long-term

intervention

The Look AHEAD Study

Does Weight Loss Reduce

Cardiovascular Disease and Death in

Overweight Individuals with Diabetes

bull Action for HEAlth in Diabetes

bull Objective to examine in overweight

persons with Type 2 Diabetes the long-

term effects of an intensive lifestyle

intervention program compared to

diabetes education and support

bull 16 Centers

bull 5145 overweight volunteers with

diabetes

Look AHEAD

Look AHEAD

Primary End Point Composite

bull Cardiovascular death (including fatal

myocardial infarction and stroke)

bull Non-fatal myocardial infarction

bull Non-fatal stroke

Winston-Salem

Baltimore

Philadelphia

New York

Providence

Boston

Clinical Site Coordinating Center

Clinical Sites

Seattle

Los Angeles

San AntonioHouston

Baton Rouge

Minneapolis

Memphis

Birmingham

Pittsburgh

Denver

Phoenix

Look AHEADParticipants

101100Baseline weight (kg)

589586Age (years)

9496Attended 1 year exam

360359Baseline BMI

1514Insulin Users

3737Minority

6059Women

(N=2574)(N=2630)

DSELifestyle

p lt 0004

Look AHEAD

Study Interventions

bull Diabetes support and education - DSE (control group)

bull Lifestyle intervention ndash ILI (treatment group)

Look AHEAD

Lifestyle Intervention

Goals

bull 7 weight loss for the group (10

for individual)

bull 175 minutes of moderate intensity

activity

Look AHEAD

Lifestyle Intervention

bull Diet

ndash ADA NCEP (lt 30 fat lt 10 sat fat

gt15 protein)

ndash 1200-1500 (if weight lt250lbs)

ndash 1500-1800 (if weight gt250lbs)

ndash During first 4 weeks to 4 months portion

control (liquid meal replacements or

structured meal plan)

Look AHEAD

Lifestyle Intervention

bull Physical Activity

ndash unsupervised

ndash 175 minutes moderate intensityweek

ndash 5 daysweek

ndash walking

Weight Loss at 1-Year

-9

ILI 0

-1

-2

-3

-4

-5

-6

-7

-8

DSE

p lt 00001

W

eig

ht

Chan

ge

86

07

The Look AHEAD Research Group Diabetes Care 2007

Reduction in Initial Weight by Gender

N=872

N=1229N=1197

N=830

-12

-10

-8

-6

-4

-2

0

0 2 4 6 8 10 12

Months

R

ed

uctio

n in

In

itia

l W

eig

ht

Men

Women

Plt0001

The Look AHEAD Research Group Diabetes Care 2007

Fitness Change () at 1-Year

0

5

10

15

20

25

Mean

Fitness C

hange

Unadjusted

Plt0001Adjusted for 1 Year

Weight Change Plt0001

58

209

108

159

DSE ILI ILIDSE

The Look AHEAD Research Group Diabetes Care 2007

1-Year Changes in Markers of

Diabetes Control

Markers of Diabetes

Control ILI DSE P-value

Hemoglobin A1c () BL

Hemoglobin A1c () Y1

Y1 ndash Baseline

725

661

-064

729

715

-014

026

lt0001

lt0001

Fasting glucose (mgdl) BL

Fasting glucose (mgdl) Y1

Y1 ndash Baseline

1519

1304

-215

1536

1464

-72

021

lt0001

lt0001

Diabetes medications BL

Diabetes medications Y1

Y1 ndash Baseline

865

786

-78

865

887

22

093

lt0001

lt0001

1-Year Changes in Markers of

Blood Pressure ControlMarkers of Blood Pressure

Control ILI DSE P-value

Systolic BP (mmHg) BL

Systolic BP (mmHg) Y1

Y1 ndash Baseline

1282

1214

-68

1294

1266

-28

026

lt0001

lt0001

Diastolic BP (mmHg) BL

Diastolic BP (mmHg) Y1

Y1 ndash Baseline

699

670

-30

704

686

-18

011

lt0001

lt0001

Antihypertensive medications BL

Antihypertensive medications Y1

Y1 ndash Baseline

753

752

-01

737

759

22

023

054

002

1-Year Changes in Markers of Lipid

Control

Markers of Lipid Control ILI DSE P-value

LDL-cholesterol (mgdl) BL

LDL-cholesterol (mgdl) Y1

Y1 ndash Baseline

1122

1070

-52

1124

1067

-57

078

074

049

HDL-cholesterol (mgdl) BL

HDL-cholesterol (mgdl) Y1

Y1 ndash Baseline

435

469

34

436

449

14

080

lt0001

lt0001

Triglycerides (mgdl) BL

Triglycerides (mgdl) Y1

Y1 ndash Baseline

1828

1525

-303

1800

1654

-146

038

lt0001

lt0001

Lipid lowering medications BL

Lipid lowering medications Y1

Y1 ndash Baseline

494

530

37

484

578

94

052

lt0001

lt0001

1-Year Changes in Percent of Participants

Meeting ADA Goals

ADA Goal ILI DSE P-value

Hemoglobin A1c lt 7 BL

Hemoglobin A1c lt 7 Y1

Y1 ndash Baseline

463

727

264

454

508

54

050

lt0001

lt0001

Blood pressure lt 13080 mmHg BL

Blood pressure lt 13080 mmHg Y1

Y1 ndash Baseline

535

686

151

499

570

70

001

lt0001

lt0001

LDL-cholesterol lt 100 mgdl BL

LDL-cholesterol lt 100 mgdl Y1

Y1 ndash Baseline

371

438

67

369

449

80

087

045

034

All three goals BL

All three goals Y1

Y1 ndash Baseline

108

236

128

95

160

65

013

lt0001

lt0001

Mean Changes in Weight Fitness amp BP

Averaged Over Four Years

DSE

Mean

ILI

Mean

P-value

Weight Loss

( initial wt)

-088 -615 lt 00001

Fitness

( METS)

196 1274 lt00001

HbA1c -009 -036 lt 00001

SBP (mm Hg) -297 -533 lt 00001

DBP (mm Hg) -248 -292 0012

Look AHEAD Research Group Arch Int Med 2010

Mean Changes in Lipid Profile

Averaged Over Four Years

DSE

Mean

ILI

Mean

P-value

HDL (mgdl) 197 367 lt00001

TG (mgdl) -1975 -2556 00006

LDL (mgdl) -1284 -1127 0009

LDL (mgdl)

(Adjusting for

medication use)

-922 -875 042

Look AHEAD Research Group Arch Int Med 2010

Percent () Completing Outcome

Measures at Years 1-4

Intervention Group

(ILI)

Year 1 971

Year 2 949

Year 3 940

Year 4 941

Comparison Group

(DSE)

Year 1 957

Year 2 935

Year 3 938

Year 4 931

Look AHEAD Summary

ILI had significantly greater improvements than DSE in all CVD risk factors averaged across 4 years (except LDL-C)

There may be long-term beneficial effects from this 4-year period in which ILI subjects have been exposed to lower CVD risk factors

Longer follow-ups will determine whether these lowered CVD risk factors can be maintained amp whether lifestyle intervention has positive effects on CVD morbidity amp mortality

Mary J

Female

White

56 years old at start of Look AHEAD

study

Past Medical History Type 2 diabetes

overweight diverticulosis arthritis

sleep apnea back pain

Mary J

bullLong term strugglesbull Helping youngest daughter with

personal issues and children

bull Rotator cuff problems

bull Degenerative disks in back

bull Rheumatoid arthritis

bull Diabetes

bull Physically demanding job

bull Financial struggles

Pounds

Years

82007 grandkids enter pre-school

Catherine L

Female

White

47 years old at start of Look AHEAD

study

Past Medical History Type 2 diabetes

overweight high blood pressure

hypothyroidism back pain

Catherine L

Long term struggles

bull Motherrsquos declining health and death

bull Multiple serious injuries

bull Sudden death of sister

bull Death of step-father

bull Declining economy

bull Children living at home

Pounds

Years

Realistic Management Goals

5-10 weight loss

Health energy and fitness

Well-being and self-esteem

Mood and appearance

Functional and recreational

activity

Key Elements

Focus on health and energy

Food and physical activity diaries

Gradual increase in physical activity

Gradual reduction in dietary fat

No feelings of food deprivation

Social support groups

Recommended Strategies for Building

Sustainable Healthy Communities

Overview from USA

Promote the availability of affordable healthy

food and beverages

Support healthy food and beverage choices

Encourage breastfeeding

Encourage physical activity or limit sedentary

activity among children amp youth

Create safe communities that support physical

activity

Encourage communities to organize for change

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Increase the availability of healthier food and

beverage choices in public service venues (eg

schools city amp county buildings etc)

--Insufficient evidence in school-based programs

--Associations suggest availability amp increased

consumption

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve availability of affordable healthier

food amp beverage choices in public service

venues

--Reducing the cost of healthier foods

increases their purchase

--Providing coupons redeemable for

healthier foods increases their purchase

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve geographic availability of

supermarkets in underserved areas

-- Greater access to nearby supermarkets is

associated with healthier eating behaviors

-- Increasing the number of supermarkets in

underserved neighborhoods increased

real estate values increased economic

activity amp employment amp resulted in lower

food prices

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Provide incentives to food retailers to locate in

andor offer healthier food choices in

underserved areas

-- Presence of retail venues that provide healthier

foods is associated with better nutrition

-- Greater availability of supermarkets was

associated with lower adolescent BMI scores

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Improve availability of mechanisms for

purchasing foods from farms

--Evidence supporting a direct link between

purchasing food from farms amp improved diet is

limited

--Two studies of initiatives to encourage

participation in farmersrsquo market showed

increased intention to eat more fruits amp

vegetables but no direct evidence

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Provide incentives for the production

distribution and procurement of foods from local

farms

--No evidence has been published to link local

food production amp health outcomes

--There is a current study exploring the potential

nutritional amp health benefits of eating locally

grown foods

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Restrict availability of less healthy foods amp

beverages in public service venues

--No peer-reviewed studies examined the impact

designed to restrict availability of less healthy

foods in public service venues

--21 states have policies that restrict the sale of

competitive foods in schools beyond USDA

regulations however no studies have evaluated

the impact of the policies

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Institute smaller portion size options in public

service venues

--Evidence is lacking to demonstrate effectiveness

of population-based interventions aimed at

reducing portion sizes in public service venues

--Evidence from clinical studies in laboratories

demonstrates decreasing portion sizes

decreases energy intake

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Limit advertisements of less healthy foods amp

beverages

--Little evidence is available regarding the impact

of restricting advertising on purchasing amp

consumption of less healthy foods

--Cross-sectional time-series studies of tobacco-

control efforts suggest an association between

advertising bans amp decreased tobacco

consumption

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Discourage consumption of sugar-sweetened

beverages

--One longitudinal study of a school-based

intervention among Native-American high school

students showed a substantial reduction in

sugar-sweetened beverages over a 3-year

period

--A RCT of a home-based intervention that

eliminated sugar-sweetened beverages showed

reduction in BMI scores

Recommended Community Strategies Strategies to encourage breastfeeding

Increase support for breastfeeding

--Evidence directly linking environmental

interventions that support breastfeeding with

obesity-related outcomes is lacking

--Epidemiologic studies indicate that breastfeeding

helps prevent pediatric obesity

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Require physical education in schools

--14 studies have demonstrated that school-based

PE was effective in increasing levels of physical

activity and improving physical fitness

--Minimum of 150 minwk in elementary schools

225 minwk in middle schools and high schools

throughout the school year as recommended by

NASPE

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Increase opportunities for extracurricular

physical activity

--Participation in after-school programs increased

studentsrsquo level of physical activity amp improved

obesity-related outcomes (improved CV fitness

reduced body fat)

--2 pilot studies providing extracurricular physical

activity showed increased levels of PA amp

decreased sedentary behavior

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Reduce screen time in public service venues

--A school-based RCT indicated that children who

reduced their television videotape amp video

game use had significant decrease in BMI tricep

skin fold thickness amp waist circumference

compared to controls

--Spending less time watching television is

associated with increased physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Improve access to outdoor recreational

facilities

--Review of 108 studies indicated that access to facilities

and programs for recreation near their homes amp time

spent outdoors correlated positively with increased

physical activity among childrenamp adults

--Perceptions that footpaths are safe for walking was

significantly associated with adults being classified as

physically active at a level sufficient for health benefits

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting

bicycling

--Longitudinal intervention studies have

demonstrated that improving bicycling

infrastructure is associated with increased

frequency of bicycling

--Cross-sectional studies indicated a significant

association between bicycling infrastructure amp

frequency of biking

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting walking

--Reviews of cross-sectional studies of

environmental correlates of physical activity amp

walking generally find a positive association

between infrastructure supportive of walking amp

physical activity

--Identifying amp creating safe routes to school

together with educational components

increased the number of students walking to

school

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Locating schools within easy walking

distance of residential areas

--Community-scale urban design amp land use policies amp

practices including locating schools stores workplaces

amp recreation areas close to residential areas are

effective in facilitating an increase in levels of physical

activity

--Majority of efforts to encourage walking to school involve

improving the routes rather than improving the location

of schools

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Improve access to public transportation

--Insufficient evidence exists to determine

effectiveness of transportation policies in

increasing the level of physical activity or

improving fitness

--1 study indicated that 29 of individuals who

walk to and from public transit achieve at least

30 minutes of daily physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Zone for mixed-use development

--Allows residential commercial institutional amp

other public land uses to be located in close

proximity to one another

--Studies using correlation analyses amp regression

models indicated that mixed land use was

associated with increased walking amp cycling

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance personal safety in areas where

persons are or could be physically active

--Cross-sectional studies have demonstrated a

negative relationship between crime rates andor

perceived safety amp physical activity in

neighborhoods

--Few intervention studies have evaluated the

impact of policies amp practices to improve

personal safety on physical activity

Geospatial Mapping Linking Urban

Environments to Health Risk

Measure association between environmental variables amp health risk factors

Assess relationships between variables at different levels of analysis

Used in conjunction with linear analyses

Our Community Environmental Model

of Obesity

Community Factors

Poverty

Crime

Grocery Quality

Restaurants

Parks

Sidewalks

Fast Food Outlets

Recreational

Facilities

Individual Factors

Dietary Intake

Physical Activity

Genetics

Family History

StressCoping

Eating Disorders

Psychological

Problems

Weight

Status

Chosen Neighborhoods

Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped

We then matched census-block groups within the income groups by population density and percentage of minority representation

One matched block group per income level was randomly selected

Prevalence of Obesity in

Block-Groups

0

5

10

15

20

25

30

35

40

45

50

Ag

e-a

dju

sted

Ob

esit

y P

rev

ale

nce

(

)

High-Income Low-Income

Age-standardized to the 1990 US Census

Density of Environmental Factors in the

Community Contributes to a ldquoToxicrdquo

Obesity Environment

0

2

4

6

8

10

12

14

16

18

Fast-food Convenience Store Bars

Den

sity

10

00

perso

ns

High-Income Low-Income

COMMUNITYrsquoS PERCEPTION OF SAFETY

0

5

10

15

20

25

30

35

40

Daytime Nighttime

Perc

en

t (

) F

eeli

ng

So

mew

hat

Safe

or

Un

safe

Low-Income High-Income

Percent Substandard (or worse) Housing

or Ground Conditions

of Residential Properties

0

10

20

30

Structural Grounds

Perc

en

t (

)

Low-Income High-Income

CONCLUSIONS

These data suggest that the higher

frequency of outlets providing

calorically-dense foods and alcohol may

contribute to greater obesity prevalence

in residents of low-income communities

More research is needed to thoroughly

document environmental determinants

of health and obesity

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

From 1994-1998 HUD randomly assigned

4498 women with children living in public

housing in high-poverty urban census

tracts to one of three groups (1) housing

vouchers redeemable only if they moved

to a low-poverty census tract (2)

unrestricted vouchers or (3) control group

(no vouchers)

Ludwig et al NEJM 201136516

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

10-12 year follow-up showed modest but

potentially important reductions in the

prevalence of extreme obesity amp diabetes in the

group moving from a neighborhood with high

poverty on one of low poverty compared to the

control group

No differences between the group receiving

traditional vouchers amp the control group

ldquoNeighborhoods matterrdquo

Ludwig et al NEJM 201136516

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance traffic safety in areas where

persons are or could be physically active

--Community-scale urban design amp land use policies to

promote physical activity including design components

to improve street lighting infrastructure projects to

increase safety of pedestrian street crossing and use of

traffic calming approaches such as speed humps amp

traffic circles are effective in increasing physical activity

--Both community-scale amp street-scale policies amp practices

are effective in increasing physical activity

Recommended Community Strategies Encourage Communities to Organize for Change

Participate in community coalitions or

partnerships to address obesity

--Little evidence is available to determine the

impact of community coalitions on obesity

prevention

--The presence of anti-smoking community

coalitions has been associated with lower rates

of tobacco consumption

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

$103 million awarded to 61 states and

communities including state amp local government

agencies tribes amp territories amp state amp local non-

profit organizations

To build capacity to implement changes for

community prevention efforts to ensure long-

term success

To implement evidence-based and practice-

based programs to improve health amp wellness

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Priority areas are

Tobacco-free living

Active living and healthy eating

Evidence-based quality clinical and other

preventive health services for prevention

and control of high blood pressure and

high cholesterol

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Applicants proposed specific activities in

line with their chosen priority areas in their

applications

Grantee activities will not be finalized until

plans are negotiated with CDC by early

2012

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Capacity-Building Award

The Confederated Tribes of The Chehalis

Reservation is receiving a $498663 planning

award to build capacity to support healthy

lifestyles among their tribal population of 1500

in Washington State

Work will target tobacco-free living active living

and healthy eating and quality clinical and other

healthy serviceswwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Implementation Award

Austin TX Dept of Health and Human Services

is receiving $1026158 to serve Travis County

(Austin) to expand efforts in tobacco-free living

active living and healthy eating quality clinical

and other preventive services social and

emotional wellness and healthy and safe

physical environmentswwwcdcgov1052011

Building sustainable healthy

communities Bottom line

Obesity is an environmental problem

Despite progress in genetic research public health advances only will occur when we take the environment seriously

Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment

Until we do this we will not make substantial progress in addressing the epidemic of obesity

Poston amp Foreyt Atherosclerosis 1999

Whatrsquos the best approach

Integrate all sectors of society into community

change interventions

Incorporate

Science amp Technology

Education

FamilyCommunity

Healthcare

Arts amp Entertainment

Law amp Politics

Commerce amp Trade

Sectors of Society

Arts amp Entertainm

ent

Commerce amp Trade

Education

FamilyCommunity

Healthcare

Law amp Politics

Science amp Technology

Project FIT rationale design and baseline characteristics of a school- and community-

based intervention to address physical activity and healthy eating among low-income

elementary school children

Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D

Oh HJ Orth J Randall S Mayfield K Holmes D

Source

Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu

Abstract

BACKGROUND

This paper describes Project FIT a collaboration between the public school system local

health systems physicians neighborhood associations businesses faith-based leaders

community agencies and university researchers to develop a multi-faceted approach to

promote physical activity and healthy eating toward the general goal of preventing and

reducing childhood obesity among children in Grand Rapids MI USA

METHODSDESIGN

There are four overall components to Project FIT school community social marketing and

school staff wellness - all that focus on 1) increasing access to safe and affordable physical

activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)

improving the affordability and availability of nutritious food in the neighborhoods surrounding

the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding

nutrition and physical activity among school staff parents and students 4) impacting the

culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging

dialogue among all community partners to leverage existing programs and introduce new

ones

Arts and Entertainment

Walking School

BusKids used to walk to school all the time Whatley says Now its almost impossible And with childhood obesity rates on the rise Whatley says walking is important because its the easiest way to exercise for a lifetime

FamilyCommunity

Health Care

Results of Lifestyle Interventions for

Weight Loss

ldquoThose who complete weight-loss programs lose approximately 10 of their body weight only to regain two-thirds of it back within one year and almost all of it back within 5 yearsrdquo

Institute of Medicine Weighing the options Criteria for evaluating

weight management programs 1995

Weekly group sessions over 4 ndash 6 months

Mean post-treatment weight reductions of ~ 8-10

Attrition rates are high at 2-yrs (mean = 39 range 20-65)

Attrition rates beyond 2-yrs (mean = 65)

Perri Foreyt amp Anton Preventing Weight

Regain After Weight Loss 2008

Results of Lifestyle Interventions for

Weight Loss

Results of Lifestyle Interventions

Pattern of Weight Regain

Weight regain occurs steadily over 2-5 yrs

Long-term follow-ups of behavioral interventions show a reliable pattern of gradual regaining of lost weight

Long-term losses of ge 5 Kg are sustained in less than 20 of patients in behavioral treatment

Perri Foreyt amp Anton Preventing Weight

Regain After Weight Loss 2008

Results of Lifestyle Interventions

Pattern of Weight Regain

ldquoThe difficulty associated with

maintaining lost weight appears to

be the result of physiological

environmental and psychological

factors that combine to facilitate a

regaining of lost weight and an

abandonment of weight control

effortsrdquo

Perri Foreyt amp Anton 2008

Population-wide prevention of obesity

Small changes in diet and physical activity may make more sense than focusing on large behavioral changes

By cutting 100 calories a day adults can prevent weight gain

Hill et al Science 2003 Hill AJCN 2009

BENEFITS OF MODEST WEIGHT LOSS

ldquoSeveral studies demonstrate that small losseshelliphelp reduce obesity-related co-morbidities and that improvements in these risk factors persist with maintenance of these modest weight lossesrdquo

Institute of Medicine 1995

- Glucose levels - HDL cholesterol levels

- Insulin levels - LDL cholesterol levels

- Glycated hemoglobin - Blood pressure

- Triglyceride levels - Quality of life levels

Stigmatization amp Discrimination

Societal beliefs that weight can be controlled thereby suggestive of character deficits (lack of willpower laziness and emotional problems)

Negative attitudes

ldquoLast safe prejudicerdquo in US society

Rand CSW Macgregor AMC South Med J 1990

DISCRIMINATION

THE PAIN OF OBESITY

Former severely obese patients

100 preferred to be deaf dyslexic

diabetic or have heart disease or bad

acne than to be obese again

Leg amputation was preferred by

915 and blindness by 894

100 preferred to be a normal weight

person rather than a severely obese

multi-millionaire Rand CSW Macgregor AMC Int J Obes 199115577ndash579

Psychosocial Burden of Obesity

Obese individuals often feel misunderstood neglected and rejected

Obese individuals have low employment prospects and are denied educational vocational and advancement opportunities

Significantly poorer quality of life

van Hout GCM van Oudheusden I amp van Heck GL Obes Surg 2004

A Healthy Lifestyle is All About

Balance

Healthy Diet

Healthy Physical Activity

Building Sustainable Healthy

Communities

Healthy Lifestyle

Building Sustainable Healthy

Communities

Healthy Lifestyle

UNFORTUNATELYhellip

Big Texan Steak Ranch

Amarillo Texas

72-oz Steak FREE if eaten within 1 hour

AVERAGE ADULT AMERICAN MAN

Height 5rsquo 8rdquo

Weight 195 lbs

Waist 397 in

BMI 284

CDC 2011

AVERAGE ADULT AMERICAN WOMAN

Height 5rsquo3rdquo

Weight 165 lbs

Waist 370 in

BMI 261

CDC 2011

Miss America

2008

Kirsten Haglund

BMI 1629

Eliana Ramos

Age 18

Height 5rsquo9rdquo

29th OLYMPIAD

BEIJING CHINA

US wrestling team captain Daniel

Cormier (2115 lbs) hospitalized for

kidney failure as result of

dehydration related to cutting weight

(did not compete)

US boxer Gary Russell was found

unconscious 4 days before his

Olympic bout due to cutting weight

(did not compete)

29th OLYMPIAD

BEIJING CHINA

Michael Phelps

8 Gold Medals SwimmingAge 23

Height 6rsquo4rdquo

Weight 195 lbs

BMI 2374

Daily Food Intake 10375 KCAL

(15 PRO 58 CHO 27 FAT)

Exercise 30 hrswk

2005 USDA FOOD PYRAMID

ldquoThe food pyramid

is too complicated

and has too many

messagesrdquo

Robert Post PhD USDA Deputy

Director 2011

2005 USDA FOOD PYRAMID

ldquoItrsquos going to be hard not to do

better than the current pyramid

which basically conveys no

useful informationrdquo

Walter C Willett MD

Chairman Department of Nutrition

Harvard School of Public Health

2011 USDA MY PLATE

ldquoWe are all

bombarded with so

many dietary

messages that it is

hard to find time to

sort through all this

informationrdquo

Michelle Obama 2011

Dietary Guidelines for Americans

2010 Two Primary Concepts

Maintain calorie balance over time to

achieve and maintain a healthy weight

Focus on consuming nutrient-dense foods

and beverages

Dietary Guidelines for Americans 2010

Efficacy-based comparative dietary guidelines

Carb Fat Pro

Mediterranean Diet 45-55 25-35 20

IOM Dietary Ref Intakes 45-65 25-35 15

NCEP-ATPIII 50-60 25-35 15

Am Dietetic Assoc 45-65 20-35 15

PARADOX OF INCREASING OBESITY

PREVALENCE

bull Focus on healthy eating and physical

activity

bull Awareness of dangers of obesity buthellip

bull Obesity prevalence continues to rise

bull Work amp commuting demands

bull Little time to exercise

bull Little time to prepare food

bull Availability of high-fatcalorie foods

Rationale for community-based interventions

bull Increases in obesity prevalence due to genes

bull Increased calories (eg 200 Kcalday

over 10 years)

bull Increased portion sizes (eg 22 oz

steaks and 44 oz sodas)

bull Western diets in developing nations

increase risk of obesity

READINESS TO CHANGE

ldquoHabit is habit and not to be

flung out of the window but

coaxed downstairs a step at a

timerdquo

Mark Twain

Long-Term Weight Maintenance

National Weight Control Registry (N=10000)

Survey of 3000 members who have been in the

Registry for at least 10 years

Starting weight = 224 lbs Average weight loss=69

lbs

At 5 years participants had maintained an average

weight loss=52 lbs

At 10 years participants had maintained an average

weight loss=51 lbs

Thomas Bond Phelan et al TOS 2011

Long-Term Weight Maintenance

Weight Maintainers report that they usually

Track their food intake

Count calories or fat grams

Follow a low-calorie low fat diet (1800 caloriesday

less than 30 of calories from fat

Eat breakfast regularly

Limit the amount they eat out (about 3 timesweek

eat fast food less than onceweek)

Thomas Bond Phelan et al TOS 2011

Long-Term Weight Maintenance

Weight Maintainers report that they usually

Eat similar food regularly

Donrsquot splurge much on holidays amp special occasions

Walk about one hourday

Watch less than 10 hours of TV a week

Weigh themselves at least once a week

Thomas Bond Phelan et al TOS 2011

LONG-TERM WEIGHT MAINTENANCE

Continued consumption of a low-

calorie diet with moderate fat intake

Limited fast food

High levels of physical activity

Phalen et al Obesity 2006 14 710-716

LONG-TERM WEIGHT MAINTENANCE

Daily weighing improved

maintenance of weight loss

particularly when delivered

face to face

Wing et al NEJM 2006 3551563-1571

Most Promising Strategies For

Preventing Weight Regain

Providing multi-component

programs with ongoing

professional contacts

Physical activityexercise

Portion controlmeal replacements

Extending treatment through

weekly or bi-weekly sessions

Pharmacotherapy

Perri Foreyt amp Anton Preventing Weight Regain After Weight Loss 2008

Most Promising Strategies For

Preventing Weight Regain

Extended treatments have shown

promise in promoting adherence to

the behaviors required for the long-

term maintenance of weight loss

Continuous care approach focused

on reasonable long-term objectives

appears appropriate for most

patients

Perri Foreyt amp Anton Preventing Weight Regain After Weight

Loss 2008

An Example of a successful long-term

intervention

The Look AHEAD Study

Does Weight Loss Reduce

Cardiovascular Disease and Death in

Overweight Individuals with Diabetes

bull Action for HEAlth in Diabetes

bull Objective to examine in overweight

persons with Type 2 Diabetes the long-

term effects of an intensive lifestyle

intervention program compared to

diabetes education and support

bull 16 Centers

bull 5145 overweight volunteers with

diabetes

Look AHEAD

Look AHEAD

Primary End Point Composite

bull Cardiovascular death (including fatal

myocardial infarction and stroke)

bull Non-fatal myocardial infarction

bull Non-fatal stroke

Winston-Salem

Baltimore

Philadelphia

New York

Providence

Boston

Clinical Site Coordinating Center

Clinical Sites

Seattle

Los Angeles

San AntonioHouston

Baton Rouge

Minneapolis

Memphis

Birmingham

Pittsburgh

Denver

Phoenix

Look AHEADParticipants

101100Baseline weight (kg)

589586Age (years)

9496Attended 1 year exam

360359Baseline BMI

1514Insulin Users

3737Minority

6059Women

(N=2574)(N=2630)

DSELifestyle

p lt 0004

Look AHEAD

Study Interventions

bull Diabetes support and education - DSE (control group)

bull Lifestyle intervention ndash ILI (treatment group)

Look AHEAD

Lifestyle Intervention

Goals

bull 7 weight loss for the group (10

for individual)

bull 175 minutes of moderate intensity

activity

Look AHEAD

Lifestyle Intervention

bull Diet

ndash ADA NCEP (lt 30 fat lt 10 sat fat

gt15 protein)

ndash 1200-1500 (if weight lt250lbs)

ndash 1500-1800 (if weight gt250lbs)

ndash During first 4 weeks to 4 months portion

control (liquid meal replacements or

structured meal plan)

Look AHEAD

Lifestyle Intervention

bull Physical Activity

ndash unsupervised

ndash 175 minutes moderate intensityweek

ndash 5 daysweek

ndash walking

Weight Loss at 1-Year

-9

ILI 0

-1

-2

-3

-4

-5

-6

-7

-8

DSE

p lt 00001

W

eig

ht

Chan

ge

86

07

The Look AHEAD Research Group Diabetes Care 2007

Reduction in Initial Weight by Gender

N=872

N=1229N=1197

N=830

-12

-10

-8

-6

-4

-2

0

0 2 4 6 8 10 12

Months

R

ed

uctio

n in

In

itia

l W

eig

ht

Men

Women

Plt0001

The Look AHEAD Research Group Diabetes Care 2007

Fitness Change () at 1-Year

0

5

10

15

20

25

Mean

Fitness C

hange

Unadjusted

Plt0001Adjusted for 1 Year

Weight Change Plt0001

58

209

108

159

DSE ILI ILIDSE

The Look AHEAD Research Group Diabetes Care 2007

1-Year Changes in Markers of

Diabetes Control

Markers of Diabetes

Control ILI DSE P-value

Hemoglobin A1c () BL

Hemoglobin A1c () Y1

Y1 ndash Baseline

725

661

-064

729

715

-014

026

lt0001

lt0001

Fasting glucose (mgdl) BL

Fasting glucose (mgdl) Y1

Y1 ndash Baseline

1519

1304

-215

1536

1464

-72

021

lt0001

lt0001

Diabetes medications BL

Diabetes medications Y1

Y1 ndash Baseline

865

786

-78

865

887

22

093

lt0001

lt0001

1-Year Changes in Markers of

Blood Pressure ControlMarkers of Blood Pressure

Control ILI DSE P-value

Systolic BP (mmHg) BL

Systolic BP (mmHg) Y1

Y1 ndash Baseline

1282

1214

-68

1294

1266

-28

026

lt0001

lt0001

Diastolic BP (mmHg) BL

Diastolic BP (mmHg) Y1

Y1 ndash Baseline

699

670

-30

704

686

-18

011

lt0001

lt0001

Antihypertensive medications BL

Antihypertensive medications Y1

Y1 ndash Baseline

753

752

-01

737

759

22

023

054

002

1-Year Changes in Markers of Lipid

Control

Markers of Lipid Control ILI DSE P-value

LDL-cholesterol (mgdl) BL

LDL-cholesterol (mgdl) Y1

Y1 ndash Baseline

1122

1070

-52

1124

1067

-57

078

074

049

HDL-cholesterol (mgdl) BL

HDL-cholesterol (mgdl) Y1

Y1 ndash Baseline

435

469

34

436

449

14

080

lt0001

lt0001

Triglycerides (mgdl) BL

Triglycerides (mgdl) Y1

Y1 ndash Baseline

1828

1525

-303

1800

1654

-146

038

lt0001

lt0001

Lipid lowering medications BL

Lipid lowering medications Y1

Y1 ndash Baseline

494

530

37

484

578

94

052

lt0001

lt0001

1-Year Changes in Percent of Participants

Meeting ADA Goals

ADA Goal ILI DSE P-value

Hemoglobin A1c lt 7 BL

Hemoglobin A1c lt 7 Y1

Y1 ndash Baseline

463

727

264

454

508

54

050

lt0001

lt0001

Blood pressure lt 13080 mmHg BL

Blood pressure lt 13080 mmHg Y1

Y1 ndash Baseline

535

686

151

499

570

70

001

lt0001

lt0001

LDL-cholesterol lt 100 mgdl BL

LDL-cholesterol lt 100 mgdl Y1

Y1 ndash Baseline

371

438

67

369

449

80

087

045

034

All three goals BL

All three goals Y1

Y1 ndash Baseline

108

236

128

95

160

65

013

lt0001

lt0001

Mean Changes in Weight Fitness amp BP

Averaged Over Four Years

DSE

Mean

ILI

Mean

P-value

Weight Loss

( initial wt)

-088 -615 lt 00001

Fitness

( METS)

196 1274 lt00001

HbA1c -009 -036 lt 00001

SBP (mm Hg) -297 -533 lt 00001

DBP (mm Hg) -248 -292 0012

Look AHEAD Research Group Arch Int Med 2010

Mean Changes in Lipid Profile

Averaged Over Four Years

DSE

Mean

ILI

Mean

P-value

HDL (mgdl) 197 367 lt00001

TG (mgdl) -1975 -2556 00006

LDL (mgdl) -1284 -1127 0009

LDL (mgdl)

(Adjusting for

medication use)

-922 -875 042

Look AHEAD Research Group Arch Int Med 2010

Percent () Completing Outcome

Measures at Years 1-4

Intervention Group

(ILI)

Year 1 971

Year 2 949

Year 3 940

Year 4 941

Comparison Group

(DSE)

Year 1 957

Year 2 935

Year 3 938

Year 4 931

Look AHEAD Summary

ILI had significantly greater improvements than DSE in all CVD risk factors averaged across 4 years (except LDL-C)

There may be long-term beneficial effects from this 4-year period in which ILI subjects have been exposed to lower CVD risk factors

Longer follow-ups will determine whether these lowered CVD risk factors can be maintained amp whether lifestyle intervention has positive effects on CVD morbidity amp mortality

Mary J

Female

White

56 years old at start of Look AHEAD

study

Past Medical History Type 2 diabetes

overweight diverticulosis arthritis

sleep apnea back pain

Mary J

bullLong term strugglesbull Helping youngest daughter with

personal issues and children

bull Rotator cuff problems

bull Degenerative disks in back

bull Rheumatoid arthritis

bull Diabetes

bull Physically demanding job

bull Financial struggles

Pounds

Years

82007 grandkids enter pre-school

Catherine L

Female

White

47 years old at start of Look AHEAD

study

Past Medical History Type 2 diabetes

overweight high blood pressure

hypothyroidism back pain

Catherine L

Long term struggles

bull Motherrsquos declining health and death

bull Multiple serious injuries

bull Sudden death of sister

bull Death of step-father

bull Declining economy

bull Children living at home

Pounds

Years

Realistic Management Goals

5-10 weight loss

Health energy and fitness

Well-being and self-esteem

Mood and appearance

Functional and recreational

activity

Key Elements

Focus on health and energy

Food and physical activity diaries

Gradual increase in physical activity

Gradual reduction in dietary fat

No feelings of food deprivation

Social support groups

Recommended Strategies for Building

Sustainable Healthy Communities

Overview from USA

Promote the availability of affordable healthy

food and beverages

Support healthy food and beverage choices

Encourage breastfeeding

Encourage physical activity or limit sedentary

activity among children amp youth

Create safe communities that support physical

activity

Encourage communities to organize for change

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Increase the availability of healthier food and

beverage choices in public service venues (eg

schools city amp county buildings etc)

--Insufficient evidence in school-based programs

--Associations suggest availability amp increased

consumption

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve availability of affordable healthier

food amp beverage choices in public service

venues

--Reducing the cost of healthier foods

increases their purchase

--Providing coupons redeemable for

healthier foods increases their purchase

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve geographic availability of

supermarkets in underserved areas

-- Greater access to nearby supermarkets is

associated with healthier eating behaviors

-- Increasing the number of supermarkets in

underserved neighborhoods increased

real estate values increased economic

activity amp employment amp resulted in lower

food prices

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Provide incentives to food retailers to locate in

andor offer healthier food choices in

underserved areas

-- Presence of retail venues that provide healthier

foods is associated with better nutrition

-- Greater availability of supermarkets was

associated with lower adolescent BMI scores

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Improve availability of mechanisms for

purchasing foods from farms

--Evidence supporting a direct link between

purchasing food from farms amp improved diet is

limited

--Two studies of initiatives to encourage

participation in farmersrsquo market showed

increased intention to eat more fruits amp

vegetables but no direct evidence

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Provide incentives for the production

distribution and procurement of foods from local

farms

--No evidence has been published to link local

food production amp health outcomes

--There is a current study exploring the potential

nutritional amp health benefits of eating locally

grown foods

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Restrict availability of less healthy foods amp

beverages in public service venues

--No peer-reviewed studies examined the impact

designed to restrict availability of less healthy

foods in public service venues

--21 states have policies that restrict the sale of

competitive foods in schools beyond USDA

regulations however no studies have evaluated

the impact of the policies

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Institute smaller portion size options in public

service venues

--Evidence is lacking to demonstrate effectiveness

of population-based interventions aimed at

reducing portion sizes in public service venues

--Evidence from clinical studies in laboratories

demonstrates decreasing portion sizes

decreases energy intake

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Limit advertisements of less healthy foods amp

beverages

--Little evidence is available regarding the impact

of restricting advertising on purchasing amp

consumption of less healthy foods

--Cross-sectional time-series studies of tobacco-

control efforts suggest an association between

advertising bans amp decreased tobacco

consumption

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Discourage consumption of sugar-sweetened

beverages

--One longitudinal study of a school-based

intervention among Native-American high school

students showed a substantial reduction in

sugar-sweetened beverages over a 3-year

period

--A RCT of a home-based intervention that

eliminated sugar-sweetened beverages showed

reduction in BMI scores

Recommended Community Strategies Strategies to encourage breastfeeding

Increase support for breastfeeding

--Evidence directly linking environmental

interventions that support breastfeeding with

obesity-related outcomes is lacking

--Epidemiologic studies indicate that breastfeeding

helps prevent pediatric obesity

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Require physical education in schools

--14 studies have demonstrated that school-based

PE was effective in increasing levels of physical

activity and improving physical fitness

--Minimum of 150 minwk in elementary schools

225 minwk in middle schools and high schools

throughout the school year as recommended by

NASPE

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Increase opportunities for extracurricular

physical activity

--Participation in after-school programs increased

studentsrsquo level of physical activity amp improved

obesity-related outcomes (improved CV fitness

reduced body fat)

--2 pilot studies providing extracurricular physical

activity showed increased levels of PA amp

decreased sedentary behavior

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Reduce screen time in public service venues

--A school-based RCT indicated that children who

reduced their television videotape amp video

game use had significant decrease in BMI tricep

skin fold thickness amp waist circumference

compared to controls

--Spending less time watching television is

associated with increased physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Improve access to outdoor recreational

facilities

--Review of 108 studies indicated that access to facilities

and programs for recreation near their homes amp time

spent outdoors correlated positively with increased

physical activity among childrenamp adults

--Perceptions that footpaths are safe for walking was

significantly associated with adults being classified as

physically active at a level sufficient for health benefits

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting

bicycling

--Longitudinal intervention studies have

demonstrated that improving bicycling

infrastructure is associated with increased

frequency of bicycling

--Cross-sectional studies indicated a significant

association between bicycling infrastructure amp

frequency of biking

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting walking

--Reviews of cross-sectional studies of

environmental correlates of physical activity amp

walking generally find a positive association

between infrastructure supportive of walking amp

physical activity

--Identifying amp creating safe routes to school

together with educational components

increased the number of students walking to

school

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Locating schools within easy walking

distance of residential areas

--Community-scale urban design amp land use policies amp

practices including locating schools stores workplaces

amp recreation areas close to residential areas are

effective in facilitating an increase in levels of physical

activity

--Majority of efforts to encourage walking to school involve

improving the routes rather than improving the location

of schools

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Improve access to public transportation

--Insufficient evidence exists to determine

effectiveness of transportation policies in

increasing the level of physical activity or

improving fitness

--1 study indicated that 29 of individuals who

walk to and from public transit achieve at least

30 minutes of daily physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Zone for mixed-use development

--Allows residential commercial institutional amp

other public land uses to be located in close

proximity to one another

--Studies using correlation analyses amp regression

models indicated that mixed land use was

associated with increased walking amp cycling

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance personal safety in areas where

persons are or could be physically active

--Cross-sectional studies have demonstrated a

negative relationship between crime rates andor

perceived safety amp physical activity in

neighborhoods

--Few intervention studies have evaluated the

impact of policies amp practices to improve

personal safety on physical activity

Geospatial Mapping Linking Urban

Environments to Health Risk

Measure association between environmental variables amp health risk factors

Assess relationships between variables at different levels of analysis

Used in conjunction with linear analyses

Our Community Environmental Model

of Obesity

Community Factors

Poverty

Crime

Grocery Quality

Restaurants

Parks

Sidewalks

Fast Food Outlets

Recreational

Facilities

Individual Factors

Dietary Intake

Physical Activity

Genetics

Family History

StressCoping

Eating Disorders

Psychological

Problems

Weight

Status

Chosen Neighborhoods

Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped

We then matched census-block groups within the income groups by population density and percentage of minority representation

One matched block group per income level was randomly selected

Prevalence of Obesity in

Block-Groups

0

5

10

15

20

25

30

35

40

45

50

Ag

e-a

dju

sted

Ob

esit

y P

rev

ale

nce

(

)

High-Income Low-Income

Age-standardized to the 1990 US Census

Density of Environmental Factors in the

Community Contributes to a ldquoToxicrdquo

Obesity Environment

0

2

4

6

8

10

12

14

16

18

Fast-food Convenience Store Bars

Den

sity

10

00

perso

ns

High-Income Low-Income

COMMUNITYrsquoS PERCEPTION OF SAFETY

0

5

10

15

20

25

30

35

40

Daytime Nighttime

Perc

en

t (

) F

eeli

ng

So

mew

hat

Safe

or

Un

safe

Low-Income High-Income

Percent Substandard (or worse) Housing

or Ground Conditions

of Residential Properties

0

10

20

30

Structural Grounds

Perc

en

t (

)

Low-Income High-Income

CONCLUSIONS

These data suggest that the higher

frequency of outlets providing

calorically-dense foods and alcohol may

contribute to greater obesity prevalence

in residents of low-income communities

More research is needed to thoroughly

document environmental determinants

of health and obesity

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

From 1994-1998 HUD randomly assigned

4498 women with children living in public

housing in high-poverty urban census

tracts to one of three groups (1) housing

vouchers redeemable only if they moved

to a low-poverty census tract (2)

unrestricted vouchers or (3) control group

(no vouchers)

Ludwig et al NEJM 201136516

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

10-12 year follow-up showed modest but

potentially important reductions in the

prevalence of extreme obesity amp diabetes in the

group moving from a neighborhood with high

poverty on one of low poverty compared to the

control group

No differences between the group receiving

traditional vouchers amp the control group

ldquoNeighborhoods matterrdquo

Ludwig et al NEJM 201136516

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance traffic safety in areas where

persons are or could be physically active

--Community-scale urban design amp land use policies to

promote physical activity including design components

to improve street lighting infrastructure projects to

increase safety of pedestrian street crossing and use of

traffic calming approaches such as speed humps amp

traffic circles are effective in increasing physical activity

--Both community-scale amp street-scale policies amp practices

are effective in increasing physical activity

Recommended Community Strategies Encourage Communities to Organize for Change

Participate in community coalitions or

partnerships to address obesity

--Little evidence is available to determine the

impact of community coalitions on obesity

prevention

--The presence of anti-smoking community

coalitions has been associated with lower rates

of tobacco consumption

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

$103 million awarded to 61 states and

communities including state amp local government

agencies tribes amp territories amp state amp local non-

profit organizations

To build capacity to implement changes for

community prevention efforts to ensure long-

term success

To implement evidence-based and practice-

based programs to improve health amp wellness

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Priority areas are

Tobacco-free living

Active living and healthy eating

Evidence-based quality clinical and other

preventive health services for prevention

and control of high blood pressure and

high cholesterol

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Applicants proposed specific activities in

line with their chosen priority areas in their

applications

Grantee activities will not be finalized until

plans are negotiated with CDC by early

2012

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Capacity-Building Award

The Confederated Tribes of The Chehalis

Reservation is receiving a $498663 planning

award to build capacity to support healthy

lifestyles among their tribal population of 1500

in Washington State

Work will target tobacco-free living active living

and healthy eating and quality clinical and other

healthy serviceswwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Implementation Award

Austin TX Dept of Health and Human Services

is receiving $1026158 to serve Travis County

(Austin) to expand efforts in tobacco-free living

active living and healthy eating quality clinical

and other preventive services social and

emotional wellness and healthy and safe

physical environmentswwwcdcgov1052011

Building sustainable healthy

communities Bottom line

Obesity is an environmental problem

Despite progress in genetic research public health advances only will occur when we take the environment seriously

Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment

Until we do this we will not make substantial progress in addressing the epidemic of obesity

Poston amp Foreyt Atherosclerosis 1999

Whatrsquos the best approach

Integrate all sectors of society into community

change interventions

Incorporate

Science amp Technology

Education

FamilyCommunity

Healthcare

Arts amp Entertainment

Law amp Politics

Commerce amp Trade

Sectors of Society

Arts amp Entertainm

ent

Commerce amp Trade

Education

FamilyCommunity

Healthcare

Law amp Politics

Science amp Technology

Project FIT rationale design and baseline characteristics of a school- and community-

based intervention to address physical activity and healthy eating among low-income

elementary school children

Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D

Oh HJ Orth J Randall S Mayfield K Holmes D

Source

Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu

Abstract

BACKGROUND

This paper describes Project FIT a collaboration between the public school system local

health systems physicians neighborhood associations businesses faith-based leaders

community agencies and university researchers to develop a multi-faceted approach to

promote physical activity and healthy eating toward the general goal of preventing and

reducing childhood obesity among children in Grand Rapids MI USA

METHODSDESIGN

There are four overall components to Project FIT school community social marketing and

school staff wellness - all that focus on 1) increasing access to safe and affordable physical

activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)

improving the affordability and availability of nutritious food in the neighborhoods surrounding

the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding

nutrition and physical activity among school staff parents and students 4) impacting the

culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging

dialogue among all community partners to leverage existing programs and introduce new

ones

Walking School

BusKids used to walk to school all the time Whatley says Now its almost impossible And with childhood obesity rates on the rise Whatley says walking is important because its the easiest way to exercise for a lifetime

FamilyCommunity

Health Care

Results of Lifestyle Interventions for

Weight Loss

ldquoThose who complete weight-loss programs lose approximately 10 of their body weight only to regain two-thirds of it back within one year and almost all of it back within 5 yearsrdquo

Institute of Medicine Weighing the options Criteria for evaluating

weight management programs 1995

Weekly group sessions over 4 ndash 6 months

Mean post-treatment weight reductions of ~ 8-10

Attrition rates are high at 2-yrs (mean = 39 range 20-65)

Attrition rates beyond 2-yrs (mean = 65)

Perri Foreyt amp Anton Preventing Weight

Regain After Weight Loss 2008

Results of Lifestyle Interventions for

Weight Loss

Results of Lifestyle Interventions

Pattern of Weight Regain

Weight regain occurs steadily over 2-5 yrs

Long-term follow-ups of behavioral interventions show a reliable pattern of gradual regaining of lost weight

Long-term losses of ge 5 Kg are sustained in less than 20 of patients in behavioral treatment

Perri Foreyt amp Anton Preventing Weight

Regain After Weight Loss 2008

Results of Lifestyle Interventions

Pattern of Weight Regain

ldquoThe difficulty associated with

maintaining lost weight appears to

be the result of physiological

environmental and psychological

factors that combine to facilitate a

regaining of lost weight and an

abandonment of weight control

effortsrdquo

Perri Foreyt amp Anton 2008

Population-wide prevention of obesity

Small changes in diet and physical activity may make more sense than focusing on large behavioral changes

By cutting 100 calories a day adults can prevent weight gain

Hill et al Science 2003 Hill AJCN 2009

BENEFITS OF MODEST WEIGHT LOSS

ldquoSeveral studies demonstrate that small losseshelliphelp reduce obesity-related co-morbidities and that improvements in these risk factors persist with maintenance of these modest weight lossesrdquo

Institute of Medicine 1995

- Glucose levels - HDL cholesterol levels

- Insulin levels - LDL cholesterol levels

- Glycated hemoglobin - Blood pressure

- Triglyceride levels - Quality of life levels

Stigmatization amp Discrimination

Societal beliefs that weight can be controlled thereby suggestive of character deficits (lack of willpower laziness and emotional problems)

Negative attitudes

ldquoLast safe prejudicerdquo in US society

Rand CSW Macgregor AMC South Med J 1990

DISCRIMINATION

THE PAIN OF OBESITY

Former severely obese patients

100 preferred to be deaf dyslexic

diabetic or have heart disease or bad

acne than to be obese again

Leg amputation was preferred by

915 and blindness by 894

100 preferred to be a normal weight

person rather than a severely obese

multi-millionaire Rand CSW Macgregor AMC Int J Obes 199115577ndash579

Psychosocial Burden of Obesity

Obese individuals often feel misunderstood neglected and rejected

Obese individuals have low employment prospects and are denied educational vocational and advancement opportunities

Significantly poorer quality of life

van Hout GCM van Oudheusden I amp van Heck GL Obes Surg 2004

A Healthy Lifestyle is All About

Balance

Healthy Diet

Healthy Physical Activity

Building Sustainable Healthy

Communities

Healthy Lifestyle

Building Sustainable Healthy

Communities

Healthy Lifestyle

UNFORTUNATELYhellip

Big Texan Steak Ranch

Amarillo Texas

72-oz Steak FREE if eaten within 1 hour

AVERAGE ADULT AMERICAN MAN

Height 5rsquo 8rdquo

Weight 195 lbs

Waist 397 in

BMI 284

CDC 2011

AVERAGE ADULT AMERICAN WOMAN

Height 5rsquo3rdquo

Weight 165 lbs

Waist 370 in

BMI 261

CDC 2011

Miss America

2008

Kirsten Haglund

BMI 1629

Eliana Ramos

Age 18

Height 5rsquo9rdquo

29th OLYMPIAD

BEIJING CHINA

US wrestling team captain Daniel

Cormier (2115 lbs) hospitalized for

kidney failure as result of

dehydration related to cutting weight

(did not compete)

US boxer Gary Russell was found

unconscious 4 days before his

Olympic bout due to cutting weight

(did not compete)

29th OLYMPIAD

BEIJING CHINA

Michael Phelps

8 Gold Medals SwimmingAge 23

Height 6rsquo4rdquo

Weight 195 lbs

BMI 2374

Daily Food Intake 10375 KCAL

(15 PRO 58 CHO 27 FAT)

Exercise 30 hrswk

2005 USDA FOOD PYRAMID

ldquoThe food pyramid

is too complicated

and has too many

messagesrdquo

Robert Post PhD USDA Deputy

Director 2011

2005 USDA FOOD PYRAMID

ldquoItrsquos going to be hard not to do

better than the current pyramid

which basically conveys no

useful informationrdquo

Walter C Willett MD

Chairman Department of Nutrition

Harvard School of Public Health

2011 USDA MY PLATE

ldquoWe are all

bombarded with so

many dietary

messages that it is

hard to find time to

sort through all this

informationrdquo

Michelle Obama 2011

Dietary Guidelines for Americans

2010 Two Primary Concepts

Maintain calorie balance over time to

achieve and maintain a healthy weight

Focus on consuming nutrient-dense foods

and beverages

Dietary Guidelines for Americans 2010

Efficacy-based comparative dietary guidelines

Carb Fat Pro

Mediterranean Diet 45-55 25-35 20

IOM Dietary Ref Intakes 45-65 25-35 15

NCEP-ATPIII 50-60 25-35 15

Am Dietetic Assoc 45-65 20-35 15

PARADOX OF INCREASING OBESITY

PREVALENCE

bull Focus on healthy eating and physical

activity

bull Awareness of dangers of obesity buthellip

bull Obesity prevalence continues to rise

bull Work amp commuting demands

bull Little time to exercise

bull Little time to prepare food

bull Availability of high-fatcalorie foods

Rationale for community-based interventions

bull Increases in obesity prevalence due to genes

bull Increased calories (eg 200 Kcalday

over 10 years)

bull Increased portion sizes (eg 22 oz

steaks and 44 oz sodas)

bull Western diets in developing nations

increase risk of obesity

READINESS TO CHANGE

ldquoHabit is habit and not to be

flung out of the window but

coaxed downstairs a step at a

timerdquo

Mark Twain

Long-Term Weight Maintenance

National Weight Control Registry (N=10000)

Survey of 3000 members who have been in the

Registry for at least 10 years

Starting weight = 224 lbs Average weight loss=69

lbs

At 5 years participants had maintained an average

weight loss=52 lbs

At 10 years participants had maintained an average

weight loss=51 lbs

Thomas Bond Phelan et al TOS 2011

Long-Term Weight Maintenance

Weight Maintainers report that they usually

Track their food intake

Count calories or fat grams

Follow a low-calorie low fat diet (1800 caloriesday

less than 30 of calories from fat

Eat breakfast regularly

Limit the amount they eat out (about 3 timesweek

eat fast food less than onceweek)

Thomas Bond Phelan et al TOS 2011

Long-Term Weight Maintenance

Weight Maintainers report that they usually

Eat similar food regularly

Donrsquot splurge much on holidays amp special occasions

Walk about one hourday

Watch less than 10 hours of TV a week

Weigh themselves at least once a week

Thomas Bond Phelan et al TOS 2011

LONG-TERM WEIGHT MAINTENANCE

Continued consumption of a low-

calorie diet with moderate fat intake

Limited fast food

High levels of physical activity

Phalen et al Obesity 2006 14 710-716

LONG-TERM WEIGHT MAINTENANCE

Daily weighing improved

maintenance of weight loss

particularly when delivered

face to face

Wing et al NEJM 2006 3551563-1571

Most Promising Strategies For

Preventing Weight Regain

Providing multi-component

programs with ongoing

professional contacts

Physical activityexercise

Portion controlmeal replacements

Extending treatment through

weekly or bi-weekly sessions

Pharmacotherapy

Perri Foreyt amp Anton Preventing Weight Regain After Weight Loss 2008

Most Promising Strategies For

Preventing Weight Regain

Extended treatments have shown

promise in promoting adherence to

the behaviors required for the long-

term maintenance of weight loss

Continuous care approach focused

on reasonable long-term objectives

appears appropriate for most

patients

Perri Foreyt amp Anton Preventing Weight Regain After Weight

Loss 2008

An Example of a successful long-term

intervention

The Look AHEAD Study

Does Weight Loss Reduce

Cardiovascular Disease and Death in

Overweight Individuals with Diabetes

bull Action for HEAlth in Diabetes

bull Objective to examine in overweight

persons with Type 2 Diabetes the long-

term effects of an intensive lifestyle

intervention program compared to

diabetes education and support

bull 16 Centers

bull 5145 overweight volunteers with

diabetes

Look AHEAD

Look AHEAD

Primary End Point Composite

bull Cardiovascular death (including fatal

myocardial infarction and stroke)

bull Non-fatal myocardial infarction

bull Non-fatal stroke

Winston-Salem

Baltimore

Philadelphia

New York

Providence

Boston

Clinical Site Coordinating Center

Clinical Sites

Seattle

Los Angeles

San AntonioHouston

Baton Rouge

Minneapolis

Memphis

Birmingham

Pittsburgh

Denver

Phoenix

Look AHEADParticipants

101100Baseline weight (kg)

589586Age (years)

9496Attended 1 year exam

360359Baseline BMI

1514Insulin Users

3737Minority

6059Women

(N=2574)(N=2630)

DSELifestyle

p lt 0004

Look AHEAD

Study Interventions

bull Diabetes support and education - DSE (control group)

bull Lifestyle intervention ndash ILI (treatment group)

Look AHEAD

Lifestyle Intervention

Goals

bull 7 weight loss for the group (10

for individual)

bull 175 minutes of moderate intensity

activity

Look AHEAD

Lifestyle Intervention

bull Diet

ndash ADA NCEP (lt 30 fat lt 10 sat fat

gt15 protein)

ndash 1200-1500 (if weight lt250lbs)

ndash 1500-1800 (if weight gt250lbs)

ndash During first 4 weeks to 4 months portion

control (liquid meal replacements or

structured meal plan)

Look AHEAD

Lifestyle Intervention

bull Physical Activity

ndash unsupervised

ndash 175 minutes moderate intensityweek

ndash 5 daysweek

ndash walking

Weight Loss at 1-Year

-9

ILI 0

-1

-2

-3

-4

-5

-6

-7

-8

DSE

p lt 00001

W

eig

ht

Chan

ge

86

07

The Look AHEAD Research Group Diabetes Care 2007

Reduction in Initial Weight by Gender

N=872

N=1229N=1197

N=830

-12

-10

-8

-6

-4

-2

0

0 2 4 6 8 10 12

Months

R

ed

uctio

n in

In

itia

l W

eig

ht

Men

Women

Plt0001

The Look AHEAD Research Group Diabetes Care 2007

Fitness Change () at 1-Year

0

5

10

15

20

25

Mean

Fitness C

hange

Unadjusted

Plt0001Adjusted for 1 Year

Weight Change Plt0001

58

209

108

159

DSE ILI ILIDSE

The Look AHEAD Research Group Diabetes Care 2007

1-Year Changes in Markers of

Diabetes Control

Markers of Diabetes

Control ILI DSE P-value

Hemoglobin A1c () BL

Hemoglobin A1c () Y1

Y1 ndash Baseline

725

661

-064

729

715

-014

026

lt0001

lt0001

Fasting glucose (mgdl) BL

Fasting glucose (mgdl) Y1

Y1 ndash Baseline

1519

1304

-215

1536

1464

-72

021

lt0001

lt0001

Diabetes medications BL

Diabetes medications Y1

Y1 ndash Baseline

865

786

-78

865

887

22

093

lt0001

lt0001

1-Year Changes in Markers of

Blood Pressure ControlMarkers of Blood Pressure

Control ILI DSE P-value

Systolic BP (mmHg) BL

Systolic BP (mmHg) Y1

Y1 ndash Baseline

1282

1214

-68

1294

1266

-28

026

lt0001

lt0001

Diastolic BP (mmHg) BL

Diastolic BP (mmHg) Y1

Y1 ndash Baseline

699

670

-30

704

686

-18

011

lt0001

lt0001

Antihypertensive medications BL

Antihypertensive medications Y1

Y1 ndash Baseline

753

752

-01

737

759

22

023

054

002

1-Year Changes in Markers of Lipid

Control

Markers of Lipid Control ILI DSE P-value

LDL-cholesterol (mgdl) BL

LDL-cholesterol (mgdl) Y1

Y1 ndash Baseline

1122

1070

-52

1124

1067

-57

078

074

049

HDL-cholesterol (mgdl) BL

HDL-cholesterol (mgdl) Y1

Y1 ndash Baseline

435

469

34

436

449

14

080

lt0001

lt0001

Triglycerides (mgdl) BL

Triglycerides (mgdl) Y1

Y1 ndash Baseline

1828

1525

-303

1800

1654

-146

038

lt0001

lt0001

Lipid lowering medications BL

Lipid lowering medications Y1

Y1 ndash Baseline

494

530

37

484

578

94

052

lt0001

lt0001

1-Year Changes in Percent of Participants

Meeting ADA Goals

ADA Goal ILI DSE P-value

Hemoglobin A1c lt 7 BL

Hemoglobin A1c lt 7 Y1

Y1 ndash Baseline

463

727

264

454

508

54

050

lt0001

lt0001

Blood pressure lt 13080 mmHg BL

Blood pressure lt 13080 mmHg Y1

Y1 ndash Baseline

535

686

151

499

570

70

001

lt0001

lt0001

LDL-cholesterol lt 100 mgdl BL

LDL-cholesterol lt 100 mgdl Y1

Y1 ndash Baseline

371

438

67

369

449

80

087

045

034

All three goals BL

All three goals Y1

Y1 ndash Baseline

108

236

128

95

160

65

013

lt0001

lt0001

Mean Changes in Weight Fitness amp BP

Averaged Over Four Years

DSE

Mean

ILI

Mean

P-value

Weight Loss

( initial wt)

-088 -615 lt 00001

Fitness

( METS)

196 1274 lt00001

HbA1c -009 -036 lt 00001

SBP (mm Hg) -297 -533 lt 00001

DBP (mm Hg) -248 -292 0012

Look AHEAD Research Group Arch Int Med 2010

Mean Changes in Lipid Profile

Averaged Over Four Years

DSE

Mean

ILI

Mean

P-value

HDL (mgdl) 197 367 lt00001

TG (mgdl) -1975 -2556 00006

LDL (mgdl) -1284 -1127 0009

LDL (mgdl)

(Adjusting for

medication use)

-922 -875 042

Look AHEAD Research Group Arch Int Med 2010

Percent () Completing Outcome

Measures at Years 1-4

Intervention Group

(ILI)

Year 1 971

Year 2 949

Year 3 940

Year 4 941

Comparison Group

(DSE)

Year 1 957

Year 2 935

Year 3 938

Year 4 931

Look AHEAD Summary

ILI had significantly greater improvements than DSE in all CVD risk factors averaged across 4 years (except LDL-C)

There may be long-term beneficial effects from this 4-year period in which ILI subjects have been exposed to lower CVD risk factors

Longer follow-ups will determine whether these lowered CVD risk factors can be maintained amp whether lifestyle intervention has positive effects on CVD morbidity amp mortality

Mary J

Female

White

56 years old at start of Look AHEAD

study

Past Medical History Type 2 diabetes

overweight diverticulosis arthritis

sleep apnea back pain

Mary J

bullLong term strugglesbull Helping youngest daughter with

personal issues and children

bull Rotator cuff problems

bull Degenerative disks in back

bull Rheumatoid arthritis

bull Diabetes

bull Physically demanding job

bull Financial struggles

Pounds

Years

82007 grandkids enter pre-school

Catherine L

Female

White

47 years old at start of Look AHEAD

study

Past Medical History Type 2 diabetes

overweight high blood pressure

hypothyroidism back pain

Catherine L

Long term struggles

bull Motherrsquos declining health and death

bull Multiple serious injuries

bull Sudden death of sister

bull Death of step-father

bull Declining economy

bull Children living at home

Pounds

Years

Realistic Management Goals

5-10 weight loss

Health energy and fitness

Well-being and self-esteem

Mood and appearance

Functional and recreational

activity

Key Elements

Focus on health and energy

Food and physical activity diaries

Gradual increase in physical activity

Gradual reduction in dietary fat

No feelings of food deprivation

Social support groups

Recommended Strategies for Building

Sustainable Healthy Communities

Overview from USA

Promote the availability of affordable healthy

food and beverages

Support healthy food and beverage choices

Encourage breastfeeding

Encourage physical activity or limit sedentary

activity among children amp youth

Create safe communities that support physical

activity

Encourage communities to organize for change

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Increase the availability of healthier food and

beverage choices in public service venues (eg

schools city amp county buildings etc)

--Insufficient evidence in school-based programs

--Associations suggest availability amp increased

consumption

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve availability of affordable healthier

food amp beverage choices in public service

venues

--Reducing the cost of healthier foods

increases their purchase

--Providing coupons redeemable for

healthier foods increases their purchase

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve geographic availability of

supermarkets in underserved areas

-- Greater access to nearby supermarkets is

associated with healthier eating behaviors

-- Increasing the number of supermarkets in

underserved neighborhoods increased

real estate values increased economic

activity amp employment amp resulted in lower

food prices

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Provide incentives to food retailers to locate in

andor offer healthier food choices in

underserved areas

-- Presence of retail venues that provide healthier

foods is associated with better nutrition

-- Greater availability of supermarkets was

associated with lower adolescent BMI scores

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Improve availability of mechanisms for

purchasing foods from farms

--Evidence supporting a direct link between

purchasing food from farms amp improved diet is

limited

--Two studies of initiatives to encourage

participation in farmersrsquo market showed

increased intention to eat more fruits amp

vegetables but no direct evidence

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Provide incentives for the production

distribution and procurement of foods from local

farms

--No evidence has been published to link local

food production amp health outcomes

--There is a current study exploring the potential

nutritional amp health benefits of eating locally

grown foods

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Restrict availability of less healthy foods amp

beverages in public service venues

--No peer-reviewed studies examined the impact

designed to restrict availability of less healthy

foods in public service venues

--21 states have policies that restrict the sale of

competitive foods in schools beyond USDA

regulations however no studies have evaluated

the impact of the policies

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Institute smaller portion size options in public

service venues

--Evidence is lacking to demonstrate effectiveness

of population-based interventions aimed at

reducing portion sizes in public service venues

--Evidence from clinical studies in laboratories

demonstrates decreasing portion sizes

decreases energy intake

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Limit advertisements of less healthy foods amp

beverages

--Little evidence is available regarding the impact

of restricting advertising on purchasing amp

consumption of less healthy foods

--Cross-sectional time-series studies of tobacco-

control efforts suggest an association between

advertising bans amp decreased tobacco

consumption

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Discourage consumption of sugar-sweetened

beverages

--One longitudinal study of a school-based

intervention among Native-American high school

students showed a substantial reduction in

sugar-sweetened beverages over a 3-year

period

--A RCT of a home-based intervention that

eliminated sugar-sweetened beverages showed

reduction in BMI scores

Recommended Community Strategies Strategies to encourage breastfeeding

Increase support for breastfeeding

--Evidence directly linking environmental

interventions that support breastfeeding with

obesity-related outcomes is lacking

--Epidemiologic studies indicate that breastfeeding

helps prevent pediatric obesity

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Require physical education in schools

--14 studies have demonstrated that school-based

PE was effective in increasing levels of physical

activity and improving physical fitness

--Minimum of 150 minwk in elementary schools

225 minwk in middle schools and high schools

throughout the school year as recommended by

NASPE

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Increase opportunities for extracurricular

physical activity

--Participation in after-school programs increased

studentsrsquo level of physical activity amp improved

obesity-related outcomes (improved CV fitness

reduced body fat)

--2 pilot studies providing extracurricular physical

activity showed increased levels of PA amp

decreased sedentary behavior

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Reduce screen time in public service venues

--A school-based RCT indicated that children who

reduced their television videotape amp video

game use had significant decrease in BMI tricep

skin fold thickness amp waist circumference

compared to controls

--Spending less time watching television is

associated with increased physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Improve access to outdoor recreational

facilities

--Review of 108 studies indicated that access to facilities

and programs for recreation near their homes amp time

spent outdoors correlated positively with increased

physical activity among childrenamp adults

--Perceptions that footpaths are safe for walking was

significantly associated with adults being classified as

physically active at a level sufficient for health benefits

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting

bicycling

--Longitudinal intervention studies have

demonstrated that improving bicycling

infrastructure is associated with increased

frequency of bicycling

--Cross-sectional studies indicated a significant

association between bicycling infrastructure amp

frequency of biking

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting walking

--Reviews of cross-sectional studies of

environmental correlates of physical activity amp

walking generally find a positive association

between infrastructure supportive of walking amp

physical activity

--Identifying amp creating safe routes to school

together with educational components

increased the number of students walking to

school

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Locating schools within easy walking

distance of residential areas

--Community-scale urban design amp land use policies amp

practices including locating schools stores workplaces

amp recreation areas close to residential areas are

effective in facilitating an increase in levels of physical

activity

--Majority of efforts to encourage walking to school involve

improving the routes rather than improving the location

of schools

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Improve access to public transportation

--Insufficient evidence exists to determine

effectiveness of transportation policies in

increasing the level of physical activity or

improving fitness

--1 study indicated that 29 of individuals who

walk to and from public transit achieve at least

30 minutes of daily physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Zone for mixed-use development

--Allows residential commercial institutional amp

other public land uses to be located in close

proximity to one another

--Studies using correlation analyses amp regression

models indicated that mixed land use was

associated with increased walking amp cycling

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance personal safety in areas where

persons are or could be physically active

--Cross-sectional studies have demonstrated a

negative relationship between crime rates andor

perceived safety amp physical activity in

neighborhoods

--Few intervention studies have evaluated the

impact of policies amp practices to improve

personal safety on physical activity

Geospatial Mapping Linking Urban

Environments to Health Risk

Measure association between environmental variables amp health risk factors

Assess relationships between variables at different levels of analysis

Used in conjunction with linear analyses

Our Community Environmental Model

of Obesity

Community Factors

Poverty

Crime

Grocery Quality

Restaurants

Parks

Sidewalks

Fast Food Outlets

Recreational

Facilities

Individual Factors

Dietary Intake

Physical Activity

Genetics

Family History

StressCoping

Eating Disorders

Psychological

Problems

Weight

Status

Chosen Neighborhoods

Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped

We then matched census-block groups within the income groups by population density and percentage of minority representation

One matched block group per income level was randomly selected

Prevalence of Obesity in

Block-Groups

0

5

10

15

20

25

30

35

40

45

50

Ag

e-a

dju

sted

Ob

esit

y P

rev

ale

nce

(

)

High-Income Low-Income

Age-standardized to the 1990 US Census

Density of Environmental Factors in the

Community Contributes to a ldquoToxicrdquo

Obesity Environment

0

2

4

6

8

10

12

14

16

18

Fast-food Convenience Store Bars

Den

sity

10

00

perso

ns

High-Income Low-Income

COMMUNITYrsquoS PERCEPTION OF SAFETY

0

5

10

15

20

25

30

35

40

Daytime Nighttime

Perc

en

t (

) F

eeli

ng

So

mew

hat

Safe

or

Un

safe

Low-Income High-Income

Percent Substandard (or worse) Housing

or Ground Conditions

of Residential Properties

0

10

20

30

Structural Grounds

Perc

en

t (

)

Low-Income High-Income

CONCLUSIONS

These data suggest that the higher

frequency of outlets providing

calorically-dense foods and alcohol may

contribute to greater obesity prevalence

in residents of low-income communities

More research is needed to thoroughly

document environmental determinants

of health and obesity

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

From 1994-1998 HUD randomly assigned

4498 women with children living in public

housing in high-poverty urban census

tracts to one of three groups (1) housing

vouchers redeemable only if they moved

to a low-poverty census tract (2)

unrestricted vouchers or (3) control group

(no vouchers)

Ludwig et al NEJM 201136516

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

10-12 year follow-up showed modest but

potentially important reductions in the

prevalence of extreme obesity amp diabetes in the

group moving from a neighborhood with high

poverty on one of low poverty compared to the

control group

No differences between the group receiving

traditional vouchers amp the control group

ldquoNeighborhoods matterrdquo

Ludwig et al NEJM 201136516

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance traffic safety in areas where

persons are or could be physically active

--Community-scale urban design amp land use policies to

promote physical activity including design components

to improve street lighting infrastructure projects to

increase safety of pedestrian street crossing and use of

traffic calming approaches such as speed humps amp

traffic circles are effective in increasing physical activity

--Both community-scale amp street-scale policies amp practices

are effective in increasing physical activity

Recommended Community Strategies Encourage Communities to Organize for Change

Participate in community coalitions or

partnerships to address obesity

--Little evidence is available to determine the

impact of community coalitions on obesity

prevention

--The presence of anti-smoking community

coalitions has been associated with lower rates

of tobacco consumption

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

$103 million awarded to 61 states and

communities including state amp local government

agencies tribes amp territories amp state amp local non-

profit organizations

To build capacity to implement changes for

community prevention efforts to ensure long-

term success

To implement evidence-based and practice-

based programs to improve health amp wellness

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Priority areas are

Tobacco-free living

Active living and healthy eating

Evidence-based quality clinical and other

preventive health services for prevention

and control of high blood pressure and

high cholesterol

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Applicants proposed specific activities in

line with their chosen priority areas in their

applications

Grantee activities will not be finalized until

plans are negotiated with CDC by early

2012

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Capacity-Building Award

The Confederated Tribes of The Chehalis

Reservation is receiving a $498663 planning

award to build capacity to support healthy

lifestyles among their tribal population of 1500

in Washington State

Work will target tobacco-free living active living

and healthy eating and quality clinical and other

healthy serviceswwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Implementation Award

Austin TX Dept of Health and Human Services

is receiving $1026158 to serve Travis County

(Austin) to expand efforts in tobacco-free living

active living and healthy eating quality clinical

and other preventive services social and

emotional wellness and healthy and safe

physical environmentswwwcdcgov1052011

Building sustainable healthy

communities Bottom line

Obesity is an environmental problem

Despite progress in genetic research public health advances only will occur when we take the environment seriously

Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment

Until we do this we will not make substantial progress in addressing the epidemic of obesity

Poston amp Foreyt Atherosclerosis 1999

Whatrsquos the best approach

Integrate all sectors of society into community

change interventions

Incorporate

Science amp Technology

Education

FamilyCommunity

Healthcare

Arts amp Entertainment

Law amp Politics

Commerce amp Trade

Sectors of Society

Arts amp Entertainm

ent

Commerce amp Trade

Education

FamilyCommunity

Healthcare

Law amp Politics

Science amp Technology

Project FIT rationale design and baseline characteristics of a school- and community-

based intervention to address physical activity and healthy eating among low-income

elementary school children

Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D

Oh HJ Orth J Randall S Mayfield K Holmes D

Source

Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu

Abstract

BACKGROUND

This paper describes Project FIT a collaboration between the public school system local

health systems physicians neighborhood associations businesses faith-based leaders

community agencies and university researchers to develop a multi-faceted approach to

promote physical activity and healthy eating toward the general goal of preventing and

reducing childhood obesity among children in Grand Rapids MI USA

METHODSDESIGN

There are four overall components to Project FIT school community social marketing and

school staff wellness - all that focus on 1) increasing access to safe and affordable physical

activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)

improving the affordability and availability of nutritious food in the neighborhoods surrounding

the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding

nutrition and physical activity among school staff parents and students 4) impacting the

culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging

dialogue among all community partners to leverage existing programs and introduce new

ones

Health Care

Results of Lifestyle Interventions for

Weight Loss

ldquoThose who complete weight-loss programs lose approximately 10 of their body weight only to regain two-thirds of it back within one year and almost all of it back within 5 yearsrdquo

Institute of Medicine Weighing the options Criteria for evaluating

weight management programs 1995

Weekly group sessions over 4 ndash 6 months

Mean post-treatment weight reductions of ~ 8-10

Attrition rates are high at 2-yrs (mean = 39 range 20-65)

Attrition rates beyond 2-yrs (mean = 65)

Perri Foreyt amp Anton Preventing Weight

Regain After Weight Loss 2008

Results of Lifestyle Interventions for

Weight Loss

Results of Lifestyle Interventions

Pattern of Weight Regain

Weight regain occurs steadily over 2-5 yrs

Long-term follow-ups of behavioral interventions show a reliable pattern of gradual regaining of lost weight

Long-term losses of ge 5 Kg are sustained in less than 20 of patients in behavioral treatment

Perri Foreyt amp Anton Preventing Weight

Regain After Weight Loss 2008

Results of Lifestyle Interventions

Pattern of Weight Regain

ldquoThe difficulty associated with

maintaining lost weight appears to

be the result of physiological

environmental and psychological

factors that combine to facilitate a

regaining of lost weight and an

abandonment of weight control

effortsrdquo

Perri Foreyt amp Anton 2008

Population-wide prevention of obesity

Small changes in diet and physical activity may make more sense than focusing on large behavioral changes

By cutting 100 calories a day adults can prevent weight gain

Hill et al Science 2003 Hill AJCN 2009

BENEFITS OF MODEST WEIGHT LOSS

ldquoSeveral studies demonstrate that small losseshelliphelp reduce obesity-related co-morbidities and that improvements in these risk factors persist with maintenance of these modest weight lossesrdquo

Institute of Medicine 1995

- Glucose levels - HDL cholesterol levels

- Insulin levels - LDL cholesterol levels

- Glycated hemoglobin - Blood pressure

- Triglyceride levels - Quality of life levels

Stigmatization amp Discrimination

Societal beliefs that weight can be controlled thereby suggestive of character deficits (lack of willpower laziness and emotional problems)

Negative attitudes

ldquoLast safe prejudicerdquo in US society

Rand CSW Macgregor AMC South Med J 1990

DISCRIMINATION

THE PAIN OF OBESITY

Former severely obese patients

100 preferred to be deaf dyslexic

diabetic or have heart disease or bad

acne than to be obese again

Leg amputation was preferred by

915 and blindness by 894

100 preferred to be a normal weight

person rather than a severely obese

multi-millionaire Rand CSW Macgregor AMC Int J Obes 199115577ndash579

Psychosocial Burden of Obesity

Obese individuals often feel misunderstood neglected and rejected

Obese individuals have low employment prospects and are denied educational vocational and advancement opportunities

Significantly poorer quality of life

van Hout GCM van Oudheusden I amp van Heck GL Obes Surg 2004

A Healthy Lifestyle is All About

Balance

Healthy Diet

Healthy Physical Activity

Building Sustainable Healthy

Communities

Healthy Lifestyle

Building Sustainable Healthy

Communities

Healthy Lifestyle

UNFORTUNATELYhellip

Big Texan Steak Ranch

Amarillo Texas

72-oz Steak FREE if eaten within 1 hour

AVERAGE ADULT AMERICAN MAN

Height 5rsquo 8rdquo

Weight 195 lbs

Waist 397 in

BMI 284

CDC 2011

AVERAGE ADULT AMERICAN WOMAN

Height 5rsquo3rdquo

Weight 165 lbs

Waist 370 in

BMI 261

CDC 2011

Miss America

2008

Kirsten Haglund

BMI 1629

Eliana Ramos

Age 18

Height 5rsquo9rdquo

29th OLYMPIAD

BEIJING CHINA

US wrestling team captain Daniel

Cormier (2115 lbs) hospitalized for

kidney failure as result of

dehydration related to cutting weight

(did not compete)

US boxer Gary Russell was found

unconscious 4 days before his

Olympic bout due to cutting weight

(did not compete)

29th OLYMPIAD

BEIJING CHINA

Michael Phelps

8 Gold Medals SwimmingAge 23

Height 6rsquo4rdquo

Weight 195 lbs

BMI 2374

Daily Food Intake 10375 KCAL

(15 PRO 58 CHO 27 FAT)

Exercise 30 hrswk

2005 USDA FOOD PYRAMID

ldquoThe food pyramid

is too complicated

and has too many

messagesrdquo

Robert Post PhD USDA Deputy

Director 2011

2005 USDA FOOD PYRAMID

ldquoItrsquos going to be hard not to do

better than the current pyramid

which basically conveys no

useful informationrdquo

Walter C Willett MD

Chairman Department of Nutrition

Harvard School of Public Health

2011 USDA MY PLATE

ldquoWe are all

bombarded with so

many dietary

messages that it is

hard to find time to

sort through all this

informationrdquo

Michelle Obama 2011

Dietary Guidelines for Americans

2010 Two Primary Concepts

Maintain calorie balance over time to

achieve and maintain a healthy weight

Focus on consuming nutrient-dense foods

and beverages

Dietary Guidelines for Americans 2010

Efficacy-based comparative dietary guidelines

Carb Fat Pro

Mediterranean Diet 45-55 25-35 20

IOM Dietary Ref Intakes 45-65 25-35 15

NCEP-ATPIII 50-60 25-35 15

Am Dietetic Assoc 45-65 20-35 15

PARADOX OF INCREASING OBESITY

PREVALENCE

bull Focus on healthy eating and physical

activity

bull Awareness of dangers of obesity buthellip

bull Obesity prevalence continues to rise

bull Work amp commuting demands

bull Little time to exercise

bull Little time to prepare food

bull Availability of high-fatcalorie foods

Rationale for community-based interventions

bull Increases in obesity prevalence due to genes

bull Increased calories (eg 200 Kcalday

over 10 years)

bull Increased portion sizes (eg 22 oz

steaks and 44 oz sodas)

bull Western diets in developing nations

increase risk of obesity

READINESS TO CHANGE

ldquoHabit is habit and not to be

flung out of the window but

coaxed downstairs a step at a

timerdquo

Mark Twain

Long-Term Weight Maintenance

National Weight Control Registry (N=10000)

Survey of 3000 members who have been in the

Registry for at least 10 years

Starting weight = 224 lbs Average weight loss=69

lbs

At 5 years participants had maintained an average

weight loss=52 lbs

At 10 years participants had maintained an average

weight loss=51 lbs

Thomas Bond Phelan et al TOS 2011

Long-Term Weight Maintenance

Weight Maintainers report that they usually

Track their food intake

Count calories or fat grams

Follow a low-calorie low fat diet (1800 caloriesday

less than 30 of calories from fat

Eat breakfast regularly

Limit the amount they eat out (about 3 timesweek

eat fast food less than onceweek)

Thomas Bond Phelan et al TOS 2011

Long-Term Weight Maintenance

Weight Maintainers report that they usually

Eat similar food regularly

Donrsquot splurge much on holidays amp special occasions

Walk about one hourday

Watch less than 10 hours of TV a week

Weigh themselves at least once a week

Thomas Bond Phelan et al TOS 2011

LONG-TERM WEIGHT MAINTENANCE

Continued consumption of a low-

calorie diet with moderate fat intake

Limited fast food

High levels of physical activity

Phalen et al Obesity 2006 14 710-716

LONG-TERM WEIGHT MAINTENANCE

Daily weighing improved

maintenance of weight loss

particularly when delivered

face to face

Wing et al NEJM 2006 3551563-1571

Most Promising Strategies For

Preventing Weight Regain

Providing multi-component

programs with ongoing

professional contacts

Physical activityexercise

Portion controlmeal replacements

Extending treatment through

weekly or bi-weekly sessions

Pharmacotherapy

Perri Foreyt amp Anton Preventing Weight Regain After Weight Loss 2008

Most Promising Strategies For

Preventing Weight Regain

Extended treatments have shown

promise in promoting adherence to

the behaviors required for the long-

term maintenance of weight loss

Continuous care approach focused

on reasonable long-term objectives

appears appropriate for most

patients

Perri Foreyt amp Anton Preventing Weight Regain After Weight

Loss 2008

An Example of a successful long-term

intervention

The Look AHEAD Study

Does Weight Loss Reduce

Cardiovascular Disease and Death in

Overweight Individuals with Diabetes

bull Action for HEAlth in Diabetes

bull Objective to examine in overweight

persons with Type 2 Diabetes the long-

term effects of an intensive lifestyle

intervention program compared to

diabetes education and support

bull 16 Centers

bull 5145 overweight volunteers with

diabetes

Look AHEAD

Look AHEAD

Primary End Point Composite

bull Cardiovascular death (including fatal

myocardial infarction and stroke)

bull Non-fatal myocardial infarction

bull Non-fatal stroke

Winston-Salem

Baltimore

Philadelphia

New York

Providence

Boston

Clinical Site Coordinating Center

Clinical Sites

Seattle

Los Angeles

San AntonioHouston

Baton Rouge

Minneapolis

Memphis

Birmingham

Pittsburgh

Denver

Phoenix

Look AHEADParticipants

101100Baseline weight (kg)

589586Age (years)

9496Attended 1 year exam

360359Baseline BMI

1514Insulin Users

3737Minority

6059Women

(N=2574)(N=2630)

DSELifestyle

p lt 0004

Look AHEAD

Study Interventions

bull Diabetes support and education - DSE (control group)

bull Lifestyle intervention ndash ILI (treatment group)

Look AHEAD

Lifestyle Intervention

Goals

bull 7 weight loss for the group (10

for individual)

bull 175 minutes of moderate intensity

activity

Look AHEAD

Lifestyle Intervention

bull Diet

ndash ADA NCEP (lt 30 fat lt 10 sat fat

gt15 protein)

ndash 1200-1500 (if weight lt250lbs)

ndash 1500-1800 (if weight gt250lbs)

ndash During first 4 weeks to 4 months portion

control (liquid meal replacements or

structured meal plan)

Look AHEAD

Lifestyle Intervention

bull Physical Activity

ndash unsupervised

ndash 175 minutes moderate intensityweek

ndash 5 daysweek

ndash walking

Weight Loss at 1-Year

-9

ILI 0

-1

-2

-3

-4

-5

-6

-7

-8

DSE

p lt 00001

W

eig

ht

Chan

ge

86

07

The Look AHEAD Research Group Diabetes Care 2007

Reduction in Initial Weight by Gender

N=872

N=1229N=1197

N=830

-12

-10

-8

-6

-4

-2

0

0 2 4 6 8 10 12

Months

R

ed

uctio

n in

In

itia

l W

eig

ht

Men

Women

Plt0001

The Look AHEAD Research Group Diabetes Care 2007

Fitness Change () at 1-Year

0

5

10

15

20

25

Mean

Fitness C

hange

Unadjusted

Plt0001Adjusted for 1 Year

Weight Change Plt0001

58

209

108

159

DSE ILI ILIDSE

The Look AHEAD Research Group Diabetes Care 2007

1-Year Changes in Markers of

Diabetes Control

Markers of Diabetes

Control ILI DSE P-value

Hemoglobin A1c () BL

Hemoglobin A1c () Y1

Y1 ndash Baseline

725

661

-064

729

715

-014

026

lt0001

lt0001

Fasting glucose (mgdl) BL

Fasting glucose (mgdl) Y1

Y1 ndash Baseline

1519

1304

-215

1536

1464

-72

021

lt0001

lt0001

Diabetes medications BL

Diabetes medications Y1

Y1 ndash Baseline

865

786

-78

865

887

22

093

lt0001

lt0001

1-Year Changes in Markers of

Blood Pressure ControlMarkers of Blood Pressure

Control ILI DSE P-value

Systolic BP (mmHg) BL

Systolic BP (mmHg) Y1

Y1 ndash Baseline

1282

1214

-68

1294

1266

-28

026

lt0001

lt0001

Diastolic BP (mmHg) BL

Diastolic BP (mmHg) Y1

Y1 ndash Baseline

699

670

-30

704

686

-18

011

lt0001

lt0001

Antihypertensive medications BL

Antihypertensive medications Y1

Y1 ndash Baseline

753

752

-01

737

759

22

023

054

002

1-Year Changes in Markers of Lipid

Control

Markers of Lipid Control ILI DSE P-value

LDL-cholesterol (mgdl) BL

LDL-cholesterol (mgdl) Y1

Y1 ndash Baseline

1122

1070

-52

1124

1067

-57

078

074

049

HDL-cholesterol (mgdl) BL

HDL-cholesterol (mgdl) Y1

Y1 ndash Baseline

435

469

34

436

449

14

080

lt0001

lt0001

Triglycerides (mgdl) BL

Triglycerides (mgdl) Y1

Y1 ndash Baseline

1828

1525

-303

1800

1654

-146

038

lt0001

lt0001

Lipid lowering medications BL

Lipid lowering medications Y1

Y1 ndash Baseline

494

530

37

484

578

94

052

lt0001

lt0001

1-Year Changes in Percent of Participants

Meeting ADA Goals

ADA Goal ILI DSE P-value

Hemoglobin A1c lt 7 BL

Hemoglobin A1c lt 7 Y1

Y1 ndash Baseline

463

727

264

454

508

54

050

lt0001

lt0001

Blood pressure lt 13080 mmHg BL

Blood pressure lt 13080 mmHg Y1

Y1 ndash Baseline

535

686

151

499

570

70

001

lt0001

lt0001

LDL-cholesterol lt 100 mgdl BL

LDL-cholesterol lt 100 mgdl Y1

Y1 ndash Baseline

371

438

67

369

449

80

087

045

034

All three goals BL

All three goals Y1

Y1 ndash Baseline

108

236

128

95

160

65

013

lt0001

lt0001

Mean Changes in Weight Fitness amp BP

Averaged Over Four Years

DSE

Mean

ILI

Mean

P-value

Weight Loss

( initial wt)

-088 -615 lt 00001

Fitness

( METS)

196 1274 lt00001

HbA1c -009 -036 lt 00001

SBP (mm Hg) -297 -533 lt 00001

DBP (mm Hg) -248 -292 0012

Look AHEAD Research Group Arch Int Med 2010

Mean Changes in Lipid Profile

Averaged Over Four Years

DSE

Mean

ILI

Mean

P-value

HDL (mgdl) 197 367 lt00001

TG (mgdl) -1975 -2556 00006

LDL (mgdl) -1284 -1127 0009

LDL (mgdl)

(Adjusting for

medication use)

-922 -875 042

Look AHEAD Research Group Arch Int Med 2010

Percent () Completing Outcome

Measures at Years 1-4

Intervention Group

(ILI)

Year 1 971

Year 2 949

Year 3 940

Year 4 941

Comparison Group

(DSE)

Year 1 957

Year 2 935

Year 3 938

Year 4 931

Look AHEAD Summary

ILI had significantly greater improvements than DSE in all CVD risk factors averaged across 4 years (except LDL-C)

There may be long-term beneficial effects from this 4-year period in which ILI subjects have been exposed to lower CVD risk factors

Longer follow-ups will determine whether these lowered CVD risk factors can be maintained amp whether lifestyle intervention has positive effects on CVD morbidity amp mortality

Mary J

Female

White

56 years old at start of Look AHEAD

study

Past Medical History Type 2 diabetes

overweight diverticulosis arthritis

sleep apnea back pain

Mary J

bullLong term strugglesbull Helping youngest daughter with

personal issues and children

bull Rotator cuff problems

bull Degenerative disks in back

bull Rheumatoid arthritis

bull Diabetes

bull Physically demanding job

bull Financial struggles

Pounds

Years

82007 grandkids enter pre-school

Catherine L

Female

White

47 years old at start of Look AHEAD

study

Past Medical History Type 2 diabetes

overweight high blood pressure

hypothyroidism back pain

Catherine L

Long term struggles

bull Motherrsquos declining health and death

bull Multiple serious injuries

bull Sudden death of sister

bull Death of step-father

bull Declining economy

bull Children living at home

Pounds

Years

Realistic Management Goals

5-10 weight loss

Health energy and fitness

Well-being and self-esteem

Mood and appearance

Functional and recreational

activity

Key Elements

Focus on health and energy

Food and physical activity diaries

Gradual increase in physical activity

Gradual reduction in dietary fat

No feelings of food deprivation

Social support groups

Recommended Strategies for Building

Sustainable Healthy Communities

Overview from USA

Promote the availability of affordable healthy

food and beverages

Support healthy food and beverage choices

Encourage breastfeeding

Encourage physical activity or limit sedentary

activity among children amp youth

Create safe communities that support physical

activity

Encourage communities to organize for change

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Increase the availability of healthier food and

beverage choices in public service venues (eg

schools city amp county buildings etc)

--Insufficient evidence in school-based programs

--Associations suggest availability amp increased

consumption

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve availability of affordable healthier

food amp beverage choices in public service

venues

--Reducing the cost of healthier foods

increases their purchase

--Providing coupons redeemable for

healthier foods increases their purchase

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve geographic availability of

supermarkets in underserved areas

-- Greater access to nearby supermarkets is

associated with healthier eating behaviors

-- Increasing the number of supermarkets in

underserved neighborhoods increased

real estate values increased economic

activity amp employment amp resulted in lower

food prices

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Provide incentives to food retailers to locate in

andor offer healthier food choices in

underserved areas

-- Presence of retail venues that provide healthier

foods is associated with better nutrition

-- Greater availability of supermarkets was

associated with lower adolescent BMI scores

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Improve availability of mechanisms for

purchasing foods from farms

--Evidence supporting a direct link between

purchasing food from farms amp improved diet is

limited

--Two studies of initiatives to encourage

participation in farmersrsquo market showed

increased intention to eat more fruits amp

vegetables but no direct evidence

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Provide incentives for the production

distribution and procurement of foods from local

farms

--No evidence has been published to link local

food production amp health outcomes

--There is a current study exploring the potential

nutritional amp health benefits of eating locally

grown foods

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Restrict availability of less healthy foods amp

beverages in public service venues

--No peer-reviewed studies examined the impact

designed to restrict availability of less healthy

foods in public service venues

--21 states have policies that restrict the sale of

competitive foods in schools beyond USDA

regulations however no studies have evaluated

the impact of the policies

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Institute smaller portion size options in public

service venues

--Evidence is lacking to demonstrate effectiveness

of population-based interventions aimed at

reducing portion sizes in public service venues

--Evidence from clinical studies in laboratories

demonstrates decreasing portion sizes

decreases energy intake

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Limit advertisements of less healthy foods amp

beverages

--Little evidence is available regarding the impact

of restricting advertising on purchasing amp

consumption of less healthy foods

--Cross-sectional time-series studies of tobacco-

control efforts suggest an association between

advertising bans amp decreased tobacco

consumption

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Discourage consumption of sugar-sweetened

beverages

--One longitudinal study of a school-based

intervention among Native-American high school

students showed a substantial reduction in

sugar-sweetened beverages over a 3-year

period

--A RCT of a home-based intervention that

eliminated sugar-sweetened beverages showed

reduction in BMI scores

Recommended Community Strategies Strategies to encourage breastfeeding

Increase support for breastfeeding

--Evidence directly linking environmental

interventions that support breastfeeding with

obesity-related outcomes is lacking

--Epidemiologic studies indicate that breastfeeding

helps prevent pediatric obesity

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Require physical education in schools

--14 studies have demonstrated that school-based

PE was effective in increasing levels of physical

activity and improving physical fitness

--Minimum of 150 minwk in elementary schools

225 minwk in middle schools and high schools

throughout the school year as recommended by

NASPE

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Increase opportunities for extracurricular

physical activity

--Participation in after-school programs increased

studentsrsquo level of physical activity amp improved

obesity-related outcomes (improved CV fitness

reduced body fat)

--2 pilot studies providing extracurricular physical

activity showed increased levels of PA amp

decreased sedentary behavior

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Reduce screen time in public service venues

--A school-based RCT indicated that children who

reduced their television videotape amp video

game use had significant decrease in BMI tricep

skin fold thickness amp waist circumference

compared to controls

--Spending less time watching television is

associated with increased physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Improve access to outdoor recreational

facilities

--Review of 108 studies indicated that access to facilities

and programs for recreation near their homes amp time

spent outdoors correlated positively with increased

physical activity among childrenamp adults

--Perceptions that footpaths are safe for walking was

significantly associated with adults being classified as

physically active at a level sufficient for health benefits

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting

bicycling

--Longitudinal intervention studies have

demonstrated that improving bicycling

infrastructure is associated with increased

frequency of bicycling

--Cross-sectional studies indicated a significant

association between bicycling infrastructure amp

frequency of biking

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting walking

--Reviews of cross-sectional studies of

environmental correlates of physical activity amp

walking generally find a positive association

between infrastructure supportive of walking amp

physical activity

--Identifying amp creating safe routes to school

together with educational components

increased the number of students walking to

school

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Locating schools within easy walking

distance of residential areas

--Community-scale urban design amp land use policies amp

practices including locating schools stores workplaces

amp recreation areas close to residential areas are

effective in facilitating an increase in levels of physical

activity

--Majority of efforts to encourage walking to school involve

improving the routes rather than improving the location

of schools

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Improve access to public transportation

--Insufficient evidence exists to determine

effectiveness of transportation policies in

increasing the level of physical activity or

improving fitness

--1 study indicated that 29 of individuals who

walk to and from public transit achieve at least

30 minutes of daily physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Zone for mixed-use development

--Allows residential commercial institutional amp

other public land uses to be located in close

proximity to one another

--Studies using correlation analyses amp regression

models indicated that mixed land use was

associated with increased walking amp cycling

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance personal safety in areas where

persons are or could be physically active

--Cross-sectional studies have demonstrated a

negative relationship between crime rates andor

perceived safety amp physical activity in

neighborhoods

--Few intervention studies have evaluated the

impact of policies amp practices to improve

personal safety on physical activity

Geospatial Mapping Linking Urban

Environments to Health Risk

Measure association between environmental variables amp health risk factors

Assess relationships between variables at different levels of analysis

Used in conjunction with linear analyses

Our Community Environmental Model

of Obesity

Community Factors

Poverty

Crime

Grocery Quality

Restaurants

Parks

Sidewalks

Fast Food Outlets

Recreational

Facilities

Individual Factors

Dietary Intake

Physical Activity

Genetics

Family History

StressCoping

Eating Disorders

Psychological

Problems

Weight

Status

Chosen Neighborhoods

Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped

We then matched census-block groups within the income groups by population density and percentage of minority representation

One matched block group per income level was randomly selected

Prevalence of Obesity in

Block-Groups

0

5

10

15

20

25

30

35

40

45

50

Ag

e-a

dju

sted

Ob

esit

y P

rev

ale

nce

(

)

High-Income Low-Income

Age-standardized to the 1990 US Census

Density of Environmental Factors in the

Community Contributes to a ldquoToxicrdquo

Obesity Environment

0

2

4

6

8

10

12

14

16

18

Fast-food Convenience Store Bars

Den

sity

10

00

perso

ns

High-Income Low-Income

COMMUNITYrsquoS PERCEPTION OF SAFETY

0

5

10

15

20

25

30

35

40

Daytime Nighttime

Perc

en

t (

) F

eeli

ng

So

mew

hat

Safe

or

Un

safe

Low-Income High-Income

Percent Substandard (or worse) Housing

or Ground Conditions

of Residential Properties

0

10

20

30

Structural Grounds

Perc

en

t (

)

Low-Income High-Income

CONCLUSIONS

These data suggest that the higher

frequency of outlets providing

calorically-dense foods and alcohol may

contribute to greater obesity prevalence

in residents of low-income communities

More research is needed to thoroughly

document environmental determinants

of health and obesity

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

From 1994-1998 HUD randomly assigned

4498 women with children living in public

housing in high-poverty urban census

tracts to one of three groups (1) housing

vouchers redeemable only if they moved

to a low-poverty census tract (2)

unrestricted vouchers or (3) control group

(no vouchers)

Ludwig et al NEJM 201136516

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

10-12 year follow-up showed modest but

potentially important reductions in the

prevalence of extreme obesity amp diabetes in the

group moving from a neighborhood with high

poverty on one of low poverty compared to the

control group

No differences between the group receiving

traditional vouchers amp the control group

ldquoNeighborhoods matterrdquo

Ludwig et al NEJM 201136516

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance traffic safety in areas where

persons are or could be physically active

--Community-scale urban design amp land use policies to

promote physical activity including design components

to improve street lighting infrastructure projects to

increase safety of pedestrian street crossing and use of

traffic calming approaches such as speed humps amp

traffic circles are effective in increasing physical activity

--Both community-scale amp street-scale policies amp practices

are effective in increasing physical activity

Recommended Community Strategies Encourage Communities to Organize for Change

Participate in community coalitions or

partnerships to address obesity

--Little evidence is available to determine the

impact of community coalitions on obesity

prevention

--The presence of anti-smoking community

coalitions has been associated with lower rates

of tobacco consumption

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

$103 million awarded to 61 states and

communities including state amp local government

agencies tribes amp territories amp state amp local non-

profit organizations

To build capacity to implement changes for

community prevention efforts to ensure long-

term success

To implement evidence-based and practice-

based programs to improve health amp wellness

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Priority areas are

Tobacco-free living

Active living and healthy eating

Evidence-based quality clinical and other

preventive health services for prevention

and control of high blood pressure and

high cholesterol

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Applicants proposed specific activities in

line with their chosen priority areas in their

applications

Grantee activities will not be finalized until

plans are negotiated with CDC by early

2012

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Capacity-Building Award

The Confederated Tribes of The Chehalis

Reservation is receiving a $498663 planning

award to build capacity to support healthy

lifestyles among their tribal population of 1500

in Washington State

Work will target tobacco-free living active living

and healthy eating and quality clinical and other

healthy serviceswwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Implementation Award

Austin TX Dept of Health and Human Services

is receiving $1026158 to serve Travis County

(Austin) to expand efforts in tobacco-free living

active living and healthy eating quality clinical

and other preventive services social and

emotional wellness and healthy and safe

physical environmentswwwcdcgov1052011

Building sustainable healthy

communities Bottom line

Obesity is an environmental problem

Despite progress in genetic research public health advances only will occur when we take the environment seriously

Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment

Until we do this we will not make substantial progress in addressing the epidemic of obesity

Poston amp Foreyt Atherosclerosis 1999

Whatrsquos the best approach

Integrate all sectors of society into community

change interventions

Incorporate

Science amp Technology

Education

FamilyCommunity

Healthcare

Arts amp Entertainment

Law amp Politics

Commerce amp Trade

Sectors of Society

Arts amp Entertainm

ent

Commerce amp Trade

Education

FamilyCommunity

Healthcare

Law amp Politics

Science amp Technology

Project FIT rationale design and baseline characteristics of a school- and community-

based intervention to address physical activity and healthy eating among low-income

elementary school children

Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D

Oh HJ Orth J Randall S Mayfield K Holmes D

Source

Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu

Abstract

BACKGROUND

This paper describes Project FIT a collaboration between the public school system local

health systems physicians neighborhood associations businesses faith-based leaders

community agencies and university researchers to develop a multi-faceted approach to

promote physical activity and healthy eating toward the general goal of preventing and

reducing childhood obesity among children in Grand Rapids MI USA

METHODSDESIGN

There are four overall components to Project FIT school community social marketing and

school staff wellness - all that focus on 1) increasing access to safe and affordable physical

activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)

improving the affordability and availability of nutritious food in the neighborhoods surrounding

the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding

nutrition and physical activity among school staff parents and students 4) impacting the

culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging

dialogue among all community partners to leverage existing programs and introduce new

ones

Results of Lifestyle Interventions for

Weight Loss

ldquoThose who complete weight-loss programs lose approximately 10 of their body weight only to regain two-thirds of it back within one year and almost all of it back within 5 yearsrdquo

Institute of Medicine Weighing the options Criteria for evaluating

weight management programs 1995

Weekly group sessions over 4 ndash 6 months

Mean post-treatment weight reductions of ~ 8-10

Attrition rates are high at 2-yrs (mean = 39 range 20-65)

Attrition rates beyond 2-yrs (mean = 65)

Perri Foreyt amp Anton Preventing Weight

Regain After Weight Loss 2008

Results of Lifestyle Interventions for

Weight Loss

Results of Lifestyle Interventions

Pattern of Weight Regain

Weight regain occurs steadily over 2-5 yrs

Long-term follow-ups of behavioral interventions show a reliable pattern of gradual regaining of lost weight

Long-term losses of ge 5 Kg are sustained in less than 20 of patients in behavioral treatment

Perri Foreyt amp Anton Preventing Weight

Regain After Weight Loss 2008

Results of Lifestyle Interventions

Pattern of Weight Regain

ldquoThe difficulty associated with

maintaining lost weight appears to

be the result of physiological

environmental and psychological

factors that combine to facilitate a

regaining of lost weight and an

abandonment of weight control

effortsrdquo

Perri Foreyt amp Anton 2008

Population-wide prevention of obesity

Small changes in diet and physical activity may make more sense than focusing on large behavioral changes

By cutting 100 calories a day adults can prevent weight gain

Hill et al Science 2003 Hill AJCN 2009

BENEFITS OF MODEST WEIGHT LOSS

ldquoSeveral studies demonstrate that small losseshelliphelp reduce obesity-related co-morbidities and that improvements in these risk factors persist with maintenance of these modest weight lossesrdquo

Institute of Medicine 1995

- Glucose levels - HDL cholesterol levels

- Insulin levels - LDL cholesterol levels

- Glycated hemoglobin - Blood pressure

- Triglyceride levels - Quality of life levels

Stigmatization amp Discrimination

Societal beliefs that weight can be controlled thereby suggestive of character deficits (lack of willpower laziness and emotional problems)

Negative attitudes

ldquoLast safe prejudicerdquo in US society

Rand CSW Macgregor AMC South Med J 1990

DISCRIMINATION

THE PAIN OF OBESITY

Former severely obese patients

100 preferred to be deaf dyslexic

diabetic or have heart disease or bad

acne than to be obese again

Leg amputation was preferred by

915 and blindness by 894

100 preferred to be a normal weight

person rather than a severely obese

multi-millionaire Rand CSW Macgregor AMC Int J Obes 199115577ndash579

Psychosocial Burden of Obesity

Obese individuals often feel misunderstood neglected and rejected

Obese individuals have low employment prospects and are denied educational vocational and advancement opportunities

Significantly poorer quality of life

van Hout GCM van Oudheusden I amp van Heck GL Obes Surg 2004

A Healthy Lifestyle is All About

Balance

Healthy Diet

Healthy Physical Activity

Building Sustainable Healthy

Communities

Healthy Lifestyle

Building Sustainable Healthy

Communities

Healthy Lifestyle

UNFORTUNATELYhellip

Big Texan Steak Ranch

Amarillo Texas

72-oz Steak FREE if eaten within 1 hour

AVERAGE ADULT AMERICAN MAN

Height 5rsquo 8rdquo

Weight 195 lbs

Waist 397 in

BMI 284

CDC 2011

AVERAGE ADULT AMERICAN WOMAN

Height 5rsquo3rdquo

Weight 165 lbs

Waist 370 in

BMI 261

CDC 2011

Miss America

2008

Kirsten Haglund

BMI 1629

Eliana Ramos

Age 18

Height 5rsquo9rdquo

29th OLYMPIAD

BEIJING CHINA

US wrestling team captain Daniel

Cormier (2115 lbs) hospitalized for

kidney failure as result of

dehydration related to cutting weight

(did not compete)

US boxer Gary Russell was found

unconscious 4 days before his

Olympic bout due to cutting weight

(did not compete)

29th OLYMPIAD

BEIJING CHINA

Michael Phelps

8 Gold Medals SwimmingAge 23

Height 6rsquo4rdquo

Weight 195 lbs

BMI 2374

Daily Food Intake 10375 KCAL

(15 PRO 58 CHO 27 FAT)

Exercise 30 hrswk

2005 USDA FOOD PYRAMID

ldquoThe food pyramid

is too complicated

and has too many

messagesrdquo

Robert Post PhD USDA Deputy

Director 2011

2005 USDA FOOD PYRAMID

ldquoItrsquos going to be hard not to do

better than the current pyramid

which basically conveys no

useful informationrdquo

Walter C Willett MD

Chairman Department of Nutrition

Harvard School of Public Health

2011 USDA MY PLATE

ldquoWe are all

bombarded with so

many dietary

messages that it is

hard to find time to

sort through all this

informationrdquo

Michelle Obama 2011

Dietary Guidelines for Americans

2010 Two Primary Concepts

Maintain calorie balance over time to

achieve and maintain a healthy weight

Focus on consuming nutrient-dense foods

and beverages

Dietary Guidelines for Americans 2010

Efficacy-based comparative dietary guidelines

Carb Fat Pro

Mediterranean Diet 45-55 25-35 20

IOM Dietary Ref Intakes 45-65 25-35 15

NCEP-ATPIII 50-60 25-35 15

Am Dietetic Assoc 45-65 20-35 15

PARADOX OF INCREASING OBESITY

PREVALENCE

bull Focus on healthy eating and physical

activity

bull Awareness of dangers of obesity buthellip

bull Obesity prevalence continues to rise

bull Work amp commuting demands

bull Little time to exercise

bull Little time to prepare food

bull Availability of high-fatcalorie foods

Rationale for community-based interventions

bull Increases in obesity prevalence due to genes

bull Increased calories (eg 200 Kcalday

over 10 years)

bull Increased portion sizes (eg 22 oz

steaks and 44 oz sodas)

bull Western diets in developing nations

increase risk of obesity

READINESS TO CHANGE

ldquoHabit is habit and not to be

flung out of the window but

coaxed downstairs a step at a

timerdquo

Mark Twain

Long-Term Weight Maintenance

National Weight Control Registry (N=10000)

Survey of 3000 members who have been in the

Registry for at least 10 years

Starting weight = 224 lbs Average weight loss=69

lbs

At 5 years participants had maintained an average

weight loss=52 lbs

At 10 years participants had maintained an average

weight loss=51 lbs

Thomas Bond Phelan et al TOS 2011

Long-Term Weight Maintenance

Weight Maintainers report that they usually

Track their food intake

Count calories or fat grams

Follow a low-calorie low fat diet (1800 caloriesday

less than 30 of calories from fat

Eat breakfast regularly

Limit the amount they eat out (about 3 timesweek

eat fast food less than onceweek)

Thomas Bond Phelan et al TOS 2011

Long-Term Weight Maintenance

Weight Maintainers report that they usually

Eat similar food regularly

Donrsquot splurge much on holidays amp special occasions

Walk about one hourday

Watch less than 10 hours of TV a week

Weigh themselves at least once a week

Thomas Bond Phelan et al TOS 2011

LONG-TERM WEIGHT MAINTENANCE

Continued consumption of a low-

calorie diet with moderate fat intake

Limited fast food

High levels of physical activity

Phalen et al Obesity 2006 14 710-716

LONG-TERM WEIGHT MAINTENANCE

Daily weighing improved

maintenance of weight loss

particularly when delivered

face to face

Wing et al NEJM 2006 3551563-1571

Most Promising Strategies For

Preventing Weight Regain

Providing multi-component

programs with ongoing

professional contacts

Physical activityexercise

Portion controlmeal replacements

Extending treatment through

weekly or bi-weekly sessions

Pharmacotherapy

Perri Foreyt amp Anton Preventing Weight Regain After Weight Loss 2008

Most Promising Strategies For

Preventing Weight Regain

Extended treatments have shown

promise in promoting adherence to

the behaviors required for the long-

term maintenance of weight loss

Continuous care approach focused

on reasonable long-term objectives

appears appropriate for most

patients

Perri Foreyt amp Anton Preventing Weight Regain After Weight

Loss 2008

An Example of a successful long-term

intervention

The Look AHEAD Study

Does Weight Loss Reduce

Cardiovascular Disease and Death in

Overweight Individuals with Diabetes

bull Action for HEAlth in Diabetes

bull Objective to examine in overweight

persons with Type 2 Diabetes the long-

term effects of an intensive lifestyle

intervention program compared to

diabetes education and support

bull 16 Centers

bull 5145 overweight volunteers with

diabetes

Look AHEAD

Look AHEAD

Primary End Point Composite

bull Cardiovascular death (including fatal

myocardial infarction and stroke)

bull Non-fatal myocardial infarction

bull Non-fatal stroke

Winston-Salem

Baltimore

Philadelphia

New York

Providence

Boston

Clinical Site Coordinating Center

Clinical Sites

Seattle

Los Angeles

San AntonioHouston

Baton Rouge

Minneapolis

Memphis

Birmingham

Pittsburgh

Denver

Phoenix

Look AHEADParticipants

101100Baseline weight (kg)

589586Age (years)

9496Attended 1 year exam

360359Baseline BMI

1514Insulin Users

3737Minority

6059Women

(N=2574)(N=2630)

DSELifestyle

p lt 0004

Look AHEAD

Study Interventions

bull Diabetes support and education - DSE (control group)

bull Lifestyle intervention ndash ILI (treatment group)

Look AHEAD

Lifestyle Intervention

Goals

bull 7 weight loss for the group (10

for individual)

bull 175 minutes of moderate intensity

activity

Look AHEAD

Lifestyle Intervention

bull Diet

ndash ADA NCEP (lt 30 fat lt 10 sat fat

gt15 protein)

ndash 1200-1500 (if weight lt250lbs)

ndash 1500-1800 (if weight gt250lbs)

ndash During first 4 weeks to 4 months portion

control (liquid meal replacements or

structured meal plan)

Look AHEAD

Lifestyle Intervention

bull Physical Activity

ndash unsupervised

ndash 175 minutes moderate intensityweek

ndash 5 daysweek

ndash walking

Weight Loss at 1-Year

-9

ILI 0

-1

-2

-3

-4

-5

-6

-7

-8

DSE

p lt 00001

W

eig

ht

Chan

ge

86

07

The Look AHEAD Research Group Diabetes Care 2007

Reduction in Initial Weight by Gender

N=872

N=1229N=1197

N=830

-12

-10

-8

-6

-4

-2

0

0 2 4 6 8 10 12

Months

R

ed

uctio

n in

In

itia

l W

eig

ht

Men

Women

Plt0001

The Look AHEAD Research Group Diabetes Care 2007

Fitness Change () at 1-Year

0

5

10

15

20

25

Mean

Fitness C

hange

Unadjusted

Plt0001Adjusted for 1 Year

Weight Change Plt0001

58

209

108

159

DSE ILI ILIDSE

The Look AHEAD Research Group Diabetes Care 2007

1-Year Changes in Markers of

Diabetes Control

Markers of Diabetes

Control ILI DSE P-value

Hemoglobin A1c () BL

Hemoglobin A1c () Y1

Y1 ndash Baseline

725

661

-064

729

715

-014

026

lt0001

lt0001

Fasting glucose (mgdl) BL

Fasting glucose (mgdl) Y1

Y1 ndash Baseline

1519

1304

-215

1536

1464

-72

021

lt0001

lt0001

Diabetes medications BL

Diabetes medications Y1

Y1 ndash Baseline

865

786

-78

865

887

22

093

lt0001

lt0001

1-Year Changes in Markers of

Blood Pressure ControlMarkers of Blood Pressure

Control ILI DSE P-value

Systolic BP (mmHg) BL

Systolic BP (mmHg) Y1

Y1 ndash Baseline

1282

1214

-68

1294

1266

-28

026

lt0001

lt0001

Diastolic BP (mmHg) BL

Diastolic BP (mmHg) Y1

Y1 ndash Baseline

699

670

-30

704

686

-18

011

lt0001

lt0001

Antihypertensive medications BL

Antihypertensive medications Y1

Y1 ndash Baseline

753

752

-01

737

759

22

023

054

002

1-Year Changes in Markers of Lipid

Control

Markers of Lipid Control ILI DSE P-value

LDL-cholesterol (mgdl) BL

LDL-cholesterol (mgdl) Y1

Y1 ndash Baseline

1122

1070

-52

1124

1067

-57

078

074

049

HDL-cholesterol (mgdl) BL

HDL-cholesterol (mgdl) Y1

Y1 ndash Baseline

435

469

34

436

449

14

080

lt0001

lt0001

Triglycerides (mgdl) BL

Triglycerides (mgdl) Y1

Y1 ndash Baseline

1828

1525

-303

1800

1654

-146

038

lt0001

lt0001

Lipid lowering medications BL

Lipid lowering medications Y1

Y1 ndash Baseline

494

530

37

484

578

94

052

lt0001

lt0001

1-Year Changes in Percent of Participants

Meeting ADA Goals

ADA Goal ILI DSE P-value

Hemoglobin A1c lt 7 BL

Hemoglobin A1c lt 7 Y1

Y1 ndash Baseline

463

727

264

454

508

54

050

lt0001

lt0001

Blood pressure lt 13080 mmHg BL

Blood pressure lt 13080 mmHg Y1

Y1 ndash Baseline

535

686

151

499

570

70

001

lt0001

lt0001

LDL-cholesterol lt 100 mgdl BL

LDL-cholesterol lt 100 mgdl Y1

Y1 ndash Baseline

371

438

67

369

449

80

087

045

034

All three goals BL

All three goals Y1

Y1 ndash Baseline

108

236

128

95

160

65

013

lt0001

lt0001

Mean Changes in Weight Fitness amp BP

Averaged Over Four Years

DSE

Mean

ILI

Mean

P-value

Weight Loss

( initial wt)

-088 -615 lt 00001

Fitness

( METS)

196 1274 lt00001

HbA1c -009 -036 lt 00001

SBP (mm Hg) -297 -533 lt 00001

DBP (mm Hg) -248 -292 0012

Look AHEAD Research Group Arch Int Med 2010

Mean Changes in Lipid Profile

Averaged Over Four Years

DSE

Mean

ILI

Mean

P-value

HDL (mgdl) 197 367 lt00001

TG (mgdl) -1975 -2556 00006

LDL (mgdl) -1284 -1127 0009

LDL (mgdl)

(Adjusting for

medication use)

-922 -875 042

Look AHEAD Research Group Arch Int Med 2010

Percent () Completing Outcome

Measures at Years 1-4

Intervention Group

(ILI)

Year 1 971

Year 2 949

Year 3 940

Year 4 941

Comparison Group

(DSE)

Year 1 957

Year 2 935

Year 3 938

Year 4 931

Look AHEAD Summary

ILI had significantly greater improvements than DSE in all CVD risk factors averaged across 4 years (except LDL-C)

There may be long-term beneficial effects from this 4-year period in which ILI subjects have been exposed to lower CVD risk factors

Longer follow-ups will determine whether these lowered CVD risk factors can be maintained amp whether lifestyle intervention has positive effects on CVD morbidity amp mortality

Mary J

Female

White

56 years old at start of Look AHEAD

study

Past Medical History Type 2 diabetes

overweight diverticulosis arthritis

sleep apnea back pain

Mary J

bullLong term strugglesbull Helping youngest daughter with

personal issues and children

bull Rotator cuff problems

bull Degenerative disks in back

bull Rheumatoid arthritis

bull Diabetes

bull Physically demanding job

bull Financial struggles

Pounds

Years

82007 grandkids enter pre-school

Catherine L

Female

White

47 years old at start of Look AHEAD

study

Past Medical History Type 2 diabetes

overweight high blood pressure

hypothyroidism back pain

Catherine L

Long term struggles

bull Motherrsquos declining health and death

bull Multiple serious injuries

bull Sudden death of sister

bull Death of step-father

bull Declining economy

bull Children living at home

Pounds

Years

Realistic Management Goals

5-10 weight loss

Health energy and fitness

Well-being and self-esteem

Mood and appearance

Functional and recreational

activity

Key Elements

Focus on health and energy

Food and physical activity diaries

Gradual increase in physical activity

Gradual reduction in dietary fat

No feelings of food deprivation

Social support groups

Recommended Strategies for Building

Sustainable Healthy Communities

Overview from USA

Promote the availability of affordable healthy

food and beverages

Support healthy food and beverage choices

Encourage breastfeeding

Encourage physical activity or limit sedentary

activity among children amp youth

Create safe communities that support physical

activity

Encourage communities to organize for change

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Increase the availability of healthier food and

beverage choices in public service venues (eg

schools city amp county buildings etc)

--Insufficient evidence in school-based programs

--Associations suggest availability amp increased

consumption

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve availability of affordable healthier

food amp beverage choices in public service

venues

--Reducing the cost of healthier foods

increases their purchase

--Providing coupons redeemable for

healthier foods increases their purchase

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve geographic availability of

supermarkets in underserved areas

-- Greater access to nearby supermarkets is

associated with healthier eating behaviors

-- Increasing the number of supermarkets in

underserved neighborhoods increased

real estate values increased economic

activity amp employment amp resulted in lower

food prices

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Provide incentives to food retailers to locate in

andor offer healthier food choices in

underserved areas

-- Presence of retail venues that provide healthier

foods is associated with better nutrition

-- Greater availability of supermarkets was

associated with lower adolescent BMI scores

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Improve availability of mechanisms for

purchasing foods from farms

--Evidence supporting a direct link between

purchasing food from farms amp improved diet is

limited

--Two studies of initiatives to encourage

participation in farmersrsquo market showed

increased intention to eat more fruits amp

vegetables but no direct evidence

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Provide incentives for the production

distribution and procurement of foods from local

farms

--No evidence has been published to link local

food production amp health outcomes

--There is a current study exploring the potential

nutritional amp health benefits of eating locally

grown foods

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Restrict availability of less healthy foods amp

beverages in public service venues

--No peer-reviewed studies examined the impact

designed to restrict availability of less healthy

foods in public service venues

--21 states have policies that restrict the sale of

competitive foods in schools beyond USDA

regulations however no studies have evaluated

the impact of the policies

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Institute smaller portion size options in public

service venues

--Evidence is lacking to demonstrate effectiveness

of population-based interventions aimed at

reducing portion sizes in public service venues

--Evidence from clinical studies in laboratories

demonstrates decreasing portion sizes

decreases energy intake

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Limit advertisements of less healthy foods amp

beverages

--Little evidence is available regarding the impact

of restricting advertising on purchasing amp

consumption of less healthy foods

--Cross-sectional time-series studies of tobacco-

control efforts suggest an association between

advertising bans amp decreased tobacco

consumption

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Discourage consumption of sugar-sweetened

beverages

--One longitudinal study of a school-based

intervention among Native-American high school

students showed a substantial reduction in

sugar-sweetened beverages over a 3-year

period

--A RCT of a home-based intervention that

eliminated sugar-sweetened beverages showed

reduction in BMI scores

Recommended Community Strategies Strategies to encourage breastfeeding

Increase support for breastfeeding

--Evidence directly linking environmental

interventions that support breastfeeding with

obesity-related outcomes is lacking

--Epidemiologic studies indicate that breastfeeding

helps prevent pediatric obesity

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Require physical education in schools

--14 studies have demonstrated that school-based

PE was effective in increasing levels of physical

activity and improving physical fitness

--Minimum of 150 minwk in elementary schools

225 minwk in middle schools and high schools

throughout the school year as recommended by

NASPE

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Increase opportunities for extracurricular

physical activity

--Participation in after-school programs increased

studentsrsquo level of physical activity amp improved

obesity-related outcomes (improved CV fitness

reduced body fat)

--2 pilot studies providing extracurricular physical

activity showed increased levels of PA amp

decreased sedentary behavior

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Reduce screen time in public service venues

--A school-based RCT indicated that children who

reduced their television videotape amp video

game use had significant decrease in BMI tricep

skin fold thickness amp waist circumference

compared to controls

--Spending less time watching television is

associated with increased physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Improve access to outdoor recreational

facilities

--Review of 108 studies indicated that access to facilities

and programs for recreation near their homes amp time

spent outdoors correlated positively with increased

physical activity among childrenamp adults

--Perceptions that footpaths are safe for walking was

significantly associated with adults being classified as

physically active at a level sufficient for health benefits

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting

bicycling

--Longitudinal intervention studies have

demonstrated that improving bicycling

infrastructure is associated with increased

frequency of bicycling

--Cross-sectional studies indicated a significant

association between bicycling infrastructure amp

frequency of biking

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting walking

--Reviews of cross-sectional studies of

environmental correlates of physical activity amp

walking generally find a positive association

between infrastructure supportive of walking amp

physical activity

--Identifying amp creating safe routes to school

together with educational components

increased the number of students walking to

school

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Locating schools within easy walking

distance of residential areas

--Community-scale urban design amp land use policies amp

practices including locating schools stores workplaces

amp recreation areas close to residential areas are

effective in facilitating an increase in levels of physical

activity

--Majority of efforts to encourage walking to school involve

improving the routes rather than improving the location

of schools

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Improve access to public transportation

--Insufficient evidence exists to determine

effectiveness of transportation policies in

increasing the level of physical activity or

improving fitness

--1 study indicated that 29 of individuals who

walk to and from public transit achieve at least

30 minutes of daily physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Zone for mixed-use development

--Allows residential commercial institutional amp

other public land uses to be located in close

proximity to one another

--Studies using correlation analyses amp regression

models indicated that mixed land use was

associated with increased walking amp cycling

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance personal safety in areas where

persons are or could be physically active

--Cross-sectional studies have demonstrated a

negative relationship between crime rates andor

perceived safety amp physical activity in

neighborhoods

--Few intervention studies have evaluated the

impact of policies amp practices to improve

personal safety on physical activity

Geospatial Mapping Linking Urban

Environments to Health Risk

Measure association between environmental variables amp health risk factors

Assess relationships between variables at different levels of analysis

Used in conjunction with linear analyses

Our Community Environmental Model

of Obesity

Community Factors

Poverty

Crime

Grocery Quality

Restaurants

Parks

Sidewalks

Fast Food Outlets

Recreational

Facilities

Individual Factors

Dietary Intake

Physical Activity

Genetics

Family History

StressCoping

Eating Disorders

Psychological

Problems

Weight

Status

Chosen Neighborhoods

Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped

We then matched census-block groups within the income groups by population density and percentage of minority representation

One matched block group per income level was randomly selected

Prevalence of Obesity in

Block-Groups

0

5

10

15

20

25

30

35

40

45

50

Ag

e-a

dju

sted

Ob

esit

y P

rev

ale

nce

(

)

High-Income Low-Income

Age-standardized to the 1990 US Census

Density of Environmental Factors in the

Community Contributes to a ldquoToxicrdquo

Obesity Environment

0

2

4

6

8

10

12

14

16

18

Fast-food Convenience Store Bars

Den

sity

10

00

perso

ns

High-Income Low-Income

COMMUNITYrsquoS PERCEPTION OF SAFETY

0

5

10

15

20

25

30

35

40

Daytime Nighttime

Perc

en

t (

) F

eeli

ng

So

mew

hat

Safe

or

Un

safe

Low-Income High-Income

Percent Substandard (or worse) Housing

or Ground Conditions

of Residential Properties

0

10

20

30

Structural Grounds

Perc

en

t (

)

Low-Income High-Income

CONCLUSIONS

These data suggest that the higher

frequency of outlets providing

calorically-dense foods and alcohol may

contribute to greater obesity prevalence

in residents of low-income communities

More research is needed to thoroughly

document environmental determinants

of health and obesity

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

From 1994-1998 HUD randomly assigned

4498 women with children living in public

housing in high-poverty urban census

tracts to one of three groups (1) housing

vouchers redeemable only if they moved

to a low-poverty census tract (2)

unrestricted vouchers or (3) control group

(no vouchers)

Ludwig et al NEJM 201136516

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

10-12 year follow-up showed modest but

potentially important reductions in the

prevalence of extreme obesity amp diabetes in the

group moving from a neighborhood with high

poverty on one of low poverty compared to the

control group

No differences between the group receiving

traditional vouchers amp the control group

ldquoNeighborhoods matterrdquo

Ludwig et al NEJM 201136516

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance traffic safety in areas where

persons are or could be physically active

--Community-scale urban design amp land use policies to

promote physical activity including design components

to improve street lighting infrastructure projects to

increase safety of pedestrian street crossing and use of

traffic calming approaches such as speed humps amp

traffic circles are effective in increasing physical activity

--Both community-scale amp street-scale policies amp practices

are effective in increasing physical activity

Recommended Community Strategies Encourage Communities to Organize for Change

Participate in community coalitions or

partnerships to address obesity

--Little evidence is available to determine the

impact of community coalitions on obesity

prevention

--The presence of anti-smoking community

coalitions has been associated with lower rates

of tobacco consumption

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

$103 million awarded to 61 states and

communities including state amp local government

agencies tribes amp territories amp state amp local non-

profit organizations

To build capacity to implement changes for

community prevention efforts to ensure long-

term success

To implement evidence-based and practice-

based programs to improve health amp wellness

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Priority areas are

Tobacco-free living

Active living and healthy eating

Evidence-based quality clinical and other

preventive health services for prevention

and control of high blood pressure and

high cholesterol

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Applicants proposed specific activities in

line with their chosen priority areas in their

applications

Grantee activities will not be finalized until

plans are negotiated with CDC by early

2012

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Capacity-Building Award

The Confederated Tribes of The Chehalis

Reservation is receiving a $498663 planning

award to build capacity to support healthy

lifestyles among their tribal population of 1500

in Washington State

Work will target tobacco-free living active living

and healthy eating and quality clinical and other

healthy serviceswwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Implementation Award

Austin TX Dept of Health and Human Services

is receiving $1026158 to serve Travis County

(Austin) to expand efforts in tobacco-free living

active living and healthy eating quality clinical

and other preventive services social and

emotional wellness and healthy and safe

physical environmentswwwcdcgov1052011

Building sustainable healthy

communities Bottom line

Obesity is an environmental problem

Despite progress in genetic research public health advances only will occur when we take the environment seriously

Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment

Until we do this we will not make substantial progress in addressing the epidemic of obesity

Poston amp Foreyt Atherosclerosis 1999

Whatrsquos the best approach

Integrate all sectors of society into community

change interventions

Incorporate

Science amp Technology

Education

FamilyCommunity

Healthcare

Arts amp Entertainment

Law amp Politics

Commerce amp Trade

Sectors of Society

Arts amp Entertainm

ent

Commerce amp Trade

Education

FamilyCommunity

Healthcare

Law amp Politics

Science amp Technology

Project FIT rationale design and baseline characteristics of a school- and community-

based intervention to address physical activity and healthy eating among low-income

elementary school children

Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D

Oh HJ Orth J Randall S Mayfield K Holmes D

Source

Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu

Abstract

BACKGROUND

This paper describes Project FIT a collaboration between the public school system local

health systems physicians neighborhood associations businesses faith-based leaders

community agencies and university researchers to develop a multi-faceted approach to

promote physical activity and healthy eating toward the general goal of preventing and

reducing childhood obesity among children in Grand Rapids MI USA

METHODSDESIGN

There are four overall components to Project FIT school community social marketing and

school staff wellness - all that focus on 1) increasing access to safe and affordable physical

activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)

improving the affordability and availability of nutritious food in the neighborhoods surrounding

the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding

nutrition and physical activity among school staff parents and students 4) impacting the

culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging

dialogue among all community partners to leverage existing programs and introduce new

ones

Weekly group sessions over 4 ndash 6 months

Mean post-treatment weight reductions of ~ 8-10

Attrition rates are high at 2-yrs (mean = 39 range 20-65)

Attrition rates beyond 2-yrs (mean = 65)

Perri Foreyt amp Anton Preventing Weight

Regain After Weight Loss 2008

Results of Lifestyle Interventions for

Weight Loss

Results of Lifestyle Interventions

Pattern of Weight Regain

Weight regain occurs steadily over 2-5 yrs

Long-term follow-ups of behavioral interventions show a reliable pattern of gradual regaining of lost weight

Long-term losses of ge 5 Kg are sustained in less than 20 of patients in behavioral treatment

Perri Foreyt amp Anton Preventing Weight

Regain After Weight Loss 2008

Results of Lifestyle Interventions

Pattern of Weight Regain

ldquoThe difficulty associated with

maintaining lost weight appears to

be the result of physiological

environmental and psychological

factors that combine to facilitate a

regaining of lost weight and an

abandonment of weight control

effortsrdquo

Perri Foreyt amp Anton 2008

Population-wide prevention of obesity

Small changes in diet and physical activity may make more sense than focusing on large behavioral changes

By cutting 100 calories a day adults can prevent weight gain

Hill et al Science 2003 Hill AJCN 2009

BENEFITS OF MODEST WEIGHT LOSS

ldquoSeveral studies demonstrate that small losseshelliphelp reduce obesity-related co-morbidities and that improvements in these risk factors persist with maintenance of these modest weight lossesrdquo

Institute of Medicine 1995

- Glucose levels - HDL cholesterol levels

- Insulin levels - LDL cholesterol levels

- Glycated hemoglobin - Blood pressure

- Triglyceride levels - Quality of life levels

Stigmatization amp Discrimination

Societal beliefs that weight can be controlled thereby suggestive of character deficits (lack of willpower laziness and emotional problems)

Negative attitudes

ldquoLast safe prejudicerdquo in US society

Rand CSW Macgregor AMC South Med J 1990

DISCRIMINATION

THE PAIN OF OBESITY

Former severely obese patients

100 preferred to be deaf dyslexic

diabetic or have heart disease or bad

acne than to be obese again

Leg amputation was preferred by

915 and blindness by 894

100 preferred to be a normal weight

person rather than a severely obese

multi-millionaire Rand CSW Macgregor AMC Int J Obes 199115577ndash579

Psychosocial Burden of Obesity

Obese individuals often feel misunderstood neglected and rejected

Obese individuals have low employment prospects and are denied educational vocational and advancement opportunities

Significantly poorer quality of life

van Hout GCM van Oudheusden I amp van Heck GL Obes Surg 2004

A Healthy Lifestyle is All About

Balance

Healthy Diet

Healthy Physical Activity

Building Sustainable Healthy

Communities

Healthy Lifestyle

Building Sustainable Healthy

Communities

Healthy Lifestyle

UNFORTUNATELYhellip

Big Texan Steak Ranch

Amarillo Texas

72-oz Steak FREE if eaten within 1 hour

AVERAGE ADULT AMERICAN MAN

Height 5rsquo 8rdquo

Weight 195 lbs

Waist 397 in

BMI 284

CDC 2011

AVERAGE ADULT AMERICAN WOMAN

Height 5rsquo3rdquo

Weight 165 lbs

Waist 370 in

BMI 261

CDC 2011

Miss America

2008

Kirsten Haglund

BMI 1629

Eliana Ramos

Age 18

Height 5rsquo9rdquo

29th OLYMPIAD

BEIJING CHINA

US wrestling team captain Daniel

Cormier (2115 lbs) hospitalized for

kidney failure as result of

dehydration related to cutting weight

(did not compete)

US boxer Gary Russell was found

unconscious 4 days before his

Olympic bout due to cutting weight

(did not compete)

29th OLYMPIAD

BEIJING CHINA

Michael Phelps

8 Gold Medals SwimmingAge 23

Height 6rsquo4rdquo

Weight 195 lbs

BMI 2374

Daily Food Intake 10375 KCAL

(15 PRO 58 CHO 27 FAT)

Exercise 30 hrswk

2005 USDA FOOD PYRAMID

ldquoThe food pyramid

is too complicated

and has too many

messagesrdquo

Robert Post PhD USDA Deputy

Director 2011

2005 USDA FOOD PYRAMID

ldquoItrsquos going to be hard not to do

better than the current pyramid

which basically conveys no

useful informationrdquo

Walter C Willett MD

Chairman Department of Nutrition

Harvard School of Public Health

2011 USDA MY PLATE

ldquoWe are all

bombarded with so

many dietary

messages that it is

hard to find time to

sort through all this

informationrdquo

Michelle Obama 2011

Dietary Guidelines for Americans

2010 Two Primary Concepts

Maintain calorie balance over time to

achieve and maintain a healthy weight

Focus on consuming nutrient-dense foods

and beverages

Dietary Guidelines for Americans 2010

Efficacy-based comparative dietary guidelines

Carb Fat Pro

Mediterranean Diet 45-55 25-35 20

IOM Dietary Ref Intakes 45-65 25-35 15

NCEP-ATPIII 50-60 25-35 15

Am Dietetic Assoc 45-65 20-35 15

PARADOX OF INCREASING OBESITY

PREVALENCE

bull Focus on healthy eating and physical

activity

bull Awareness of dangers of obesity buthellip

bull Obesity prevalence continues to rise

bull Work amp commuting demands

bull Little time to exercise

bull Little time to prepare food

bull Availability of high-fatcalorie foods

Rationale for community-based interventions

bull Increases in obesity prevalence due to genes

bull Increased calories (eg 200 Kcalday

over 10 years)

bull Increased portion sizes (eg 22 oz

steaks and 44 oz sodas)

bull Western diets in developing nations

increase risk of obesity

READINESS TO CHANGE

ldquoHabit is habit and not to be

flung out of the window but

coaxed downstairs a step at a

timerdquo

Mark Twain

Long-Term Weight Maintenance

National Weight Control Registry (N=10000)

Survey of 3000 members who have been in the

Registry for at least 10 years

Starting weight = 224 lbs Average weight loss=69

lbs

At 5 years participants had maintained an average

weight loss=52 lbs

At 10 years participants had maintained an average

weight loss=51 lbs

Thomas Bond Phelan et al TOS 2011

Long-Term Weight Maintenance

Weight Maintainers report that they usually

Track their food intake

Count calories or fat grams

Follow a low-calorie low fat diet (1800 caloriesday

less than 30 of calories from fat

Eat breakfast regularly

Limit the amount they eat out (about 3 timesweek

eat fast food less than onceweek)

Thomas Bond Phelan et al TOS 2011

Long-Term Weight Maintenance

Weight Maintainers report that they usually

Eat similar food regularly

Donrsquot splurge much on holidays amp special occasions

Walk about one hourday

Watch less than 10 hours of TV a week

Weigh themselves at least once a week

Thomas Bond Phelan et al TOS 2011

LONG-TERM WEIGHT MAINTENANCE

Continued consumption of a low-

calorie diet with moderate fat intake

Limited fast food

High levels of physical activity

Phalen et al Obesity 2006 14 710-716

LONG-TERM WEIGHT MAINTENANCE

Daily weighing improved

maintenance of weight loss

particularly when delivered

face to face

Wing et al NEJM 2006 3551563-1571

Most Promising Strategies For

Preventing Weight Regain

Providing multi-component

programs with ongoing

professional contacts

Physical activityexercise

Portion controlmeal replacements

Extending treatment through

weekly or bi-weekly sessions

Pharmacotherapy

Perri Foreyt amp Anton Preventing Weight Regain After Weight Loss 2008

Most Promising Strategies For

Preventing Weight Regain

Extended treatments have shown

promise in promoting adherence to

the behaviors required for the long-

term maintenance of weight loss

Continuous care approach focused

on reasonable long-term objectives

appears appropriate for most

patients

Perri Foreyt amp Anton Preventing Weight Regain After Weight

Loss 2008

An Example of a successful long-term

intervention

The Look AHEAD Study

Does Weight Loss Reduce

Cardiovascular Disease and Death in

Overweight Individuals with Diabetes

bull Action for HEAlth in Diabetes

bull Objective to examine in overweight

persons with Type 2 Diabetes the long-

term effects of an intensive lifestyle

intervention program compared to

diabetes education and support

bull 16 Centers

bull 5145 overweight volunteers with

diabetes

Look AHEAD

Look AHEAD

Primary End Point Composite

bull Cardiovascular death (including fatal

myocardial infarction and stroke)

bull Non-fatal myocardial infarction

bull Non-fatal stroke

Winston-Salem

Baltimore

Philadelphia

New York

Providence

Boston

Clinical Site Coordinating Center

Clinical Sites

Seattle

Los Angeles

San AntonioHouston

Baton Rouge

Minneapolis

Memphis

Birmingham

Pittsburgh

Denver

Phoenix

Look AHEADParticipants

101100Baseline weight (kg)

589586Age (years)

9496Attended 1 year exam

360359Baseline BMI

1514Insulin Users

3737Minority

6059Women

(N=2574)(N=2630)

DSELifestyle

p lt 0004

Look AHEAD

Study Interventions

bull Diabetes support and education - DSE (control group)

bull Lifestyle intervention ndash ILI (treatment group)

Look AHEAD

Lifestyle Intervention

Goals

bull 7 weight loss for the group (10

for individual)

bull 175 minutes of moderate intensity

activity

Look AHEAD

Lifestyle Intervention

bull Diet

ndash ADA NCEP (lt 30 fat lt 10 sat fat

gt15 protein)

ndash 1200-1500 (if weight lt250lbs)

ndash 1500-1800 (if weight gt250lbs)

ndash During first 4 weeks to 4 months portion

control (liquid meal replacements or

structured meal plan)

Look AHEAD

Lifestyle Intervention

bull Physical Activity

ndash unsupervised

ndash 175 minutes moderate intensityweek

ndash 5 daysweek

ndash walking

Weight Loss at 1-Year

-9

ILI 0

-1

-2

-3

-4

-5

-6

-7

-8

DSE

p lt 00001

W

eig

ht

Chan

ge

86

07

The Look AHEAD Research Group Diabetes Care 2007

Reduction in Initial Weight by Gender

N=872

N=1229N=1197

N=830

-12

-10

-8

-6

-4

-2

0

0 2 4 6 8 10 12

Months

R

ed

uctio

n in

In

itia

l W

eig

ht

Men

Women

Plt0001

The Look AHEAD Research Group Diabetes Care 2007

Fitness Change () at 1-Year

0

5

10

15

20

25

Mean

Fitness C

hange

Unadjusted

Plt0001Adjusted for 1 Year

Weight Change Plt0001

58

209

108

159

DSE ILI ILIDSE

The Look AHEAD Research Group Diabetes Care 2007

1-Year Changes in Markers of

Diabetes Control

Markers of Diabetes

Control ILI DSE P-value

Hemoglobin A1c () BL

Hemoglobin A1c () Y1

Y1 ndash Baseline

725

661

-064

729

715

-014

026

lt0001

lt0001

Fasting glucose (mgdl) BL

Fasting glucose (mgdl) Y1

Y1 ndash Baseline

1519

1304

-215

1536

1464

-72

021

lt0001

lt0001

Diabetes medications BL

Diabetes medications Y1

Y1 ndash Baseline

865

786

-78

865

887

22

093

lt0001

lt0001

1-Year Changes in Markers of

Blood Pressure ControlMarkers of Blood Pressure

Control ILI DSE P-value

Systolic BP (mmHg) BL

Systolic BP (mmHg) Y1

Y1 ndash Baseline

1282

1214

-68

1294

1266

-28

026

lt0001

lt0001

Diastolic BP (mmHg) BL

Diastolic BP (mmHg) Y1

Y1 ndash Baseline

699

670

-30

704

686

-18

011

lt0001

lt0001

Antihypertensive medications BL

Antihypertensive medications Y1

Y1 ndash Baseline

753

752

-01

737

759

22

023

054

002

1-Year Changes in Markers of Lipid

Control

Markers of Lipid Control ILI DSE P-value

LDL-cholesterol (mgdl) BL

LDL-cholesterol (mgdl) Y1

Y1 ndash Baseline

1122

1070

-52

1124

1067

-57

078

074

049

HDL-cholesterol (mgdl) BL

HDL-cholesterol (mgdl) Y1

Y1 ndash Baseline

435

469

34

436

449

14

080

lt0001

lt0001

Triglycerides (mgdl) BL

Triglycerides (mgdl) Y1

Y1 ndash Baseline

1828

1525

-303

1800

1654

-146

038

lt0001

lt0001

Lipid lowering medications BL

Lipid lowering medications Y1

Y1 ndash Baseline

494

530

37

484

578

94

052

lt0001

lt0001

1-Year Changes in Percent of Participants

Meeting ADA Goals

ADA Goal ILI DSE P-value

Hemoglobin A1c lt 7 BL

Hemoglobin A1c lt 7 Y1

Y1 ndash Baseline

463

727

264

454

508

54

050

lt0001

lt0001

Blood pressure lt 13080 mmHg BL

Blood pressure lt 13080 mmHg Y1

Y1 ndash Baseline

535

686

151

499

570

70

001

lt0001

lt0001

LDL-cholesterol lt 100 mgdl BL

LDL-cholesterol lt 100 mgdl Y1

Y1 ndash Baseline

371

438

67

369

449

80

087

045

034

All three goals BL

All three goals Y1

Y1 ndash Baseline

108

236

128

95

160

65

013

lt0001

lt0001

Mean Changes in Weight Fitness amp BP

Averaged Over Four Years

DSE

Mean

ILI

Mean

P-value

Weight Loss

( initial wt)

-088 -615 lt 00001

Fitness

( METS)

196 1274 lt00001

HbA1c -009 -036 lt 00001

SBP (mm Hg) -297 -533 lt 00001

DBP (mm Hg) -248 -292 0012

Look AHEAD Research Group Arch Int Med 2010

Mean Changes in Lipid Profile

Averaged Over Four Years

DSE

Mean

ILI

Mean

P-value

HDL (mgdl) 197 367 lt00001

TG (mgdl) -1975 -2556 00006

LDL (mgdl) -1284 -1127 0009

LDL (mgdl)

(Adjusting for

medication use)

-922 -875 042

Look AHEAD Research Group Arch Int Med 2010

Percent () Completing Outcome

Measures at Years 1-4

Intervention Group

(ILI)

Year 1 971

Year 2 949

Year 3 940

Year 4 941

Comparison Group

(DSE)

Year 1 957

Year 2 935

Year 3 938

Year 4 931

Look AHEAD Summary

ILI had significantly greater improvements than DSE in all CVD risk factors averaged across 4 years (except LDL-C)

There may be long-term beneficial effects from this 4-year period in which ILI subjects have been exposed to lower CVD risk factors

Longer follow-ups will determine whether these lowered CVD risk factors can be maintained amp whether lifestyle intervention has positive effects on CVD morbidity amp mortality

Mary J

Female

White

56 years old at start of Look AHEAD

study

Past Medical History Type 2 diabetes

overweight diverticulosis arthritis

sleep apnea back pain

Mary J

bullLong term strugglesbull Helping youngest daughter with

personal issues and children

bull Rotator cuff problems

bull Degenerative disks in back

bull Rheumatoid arthritis

bull Diabetes

bull Physically demanding job

bull Financial struggles

Pounds

Years

82007 grandkids enter pre-school

Catherine L

Female

White

47 years old at start of Look AHEAD

study

Past Medical History Type 2 diabetes

overweight high blood pressure

hypothyroidism back pain

Catherine L

Long term struggles

bull Motherrsquos declining health and death

bull Multiple serious injuries

bull Sudden death of sister

bull Death of step-father

bull Declining economy

bull Children living at home

Pounds

Years

Realistic Management Goals

5-10 weight loss

Health energy and fitness

Well-being and self-esteem

Mood and appearance

Functional and recreational

activity

Key Elements

Focus on health and energy

Food and physical activity diaries

Gradual increase in physical activity

Gradual reduction in dietary fat

No feelings of food deprivation

Social support groups

Recommended Strategies for Building

Sustainable Healthy Communities

Overview from USA

Promote the availability of affordable healthy

food and beverages

Support healthy food and beverage choices

Encourage breastfeeding

Encourage physical activity or limit sedentary

activity among children amp youth

Create safe communities that support physical

activity

Encourage communities to organize for change

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Increase the availability of healthier food and

beverage choices in public service venues (eg

schools city amp county buildings etc)

--Insufficient evidence in school-based programs

--Associations suggest availability amp increased

consumption

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve availability of affordable healthier

food amp beverage choices in public service

venues

--Reducing the cost of healthier foods

increases their purchase

--Providing coupons redeemable for

healthier foods increases their purchase

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve geographic availability of

supermarkets in underserved areas

-- Greater access to nearby supermarkets is

associated with healthier eating behaviors

-- Increasing the number of supermarkets in

underserved neighborhoods increased

real estate values increased economic

activity amp employment amp resulted in lower

food prices

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Provide incentives to food retailers to locate in

andor offer healthier food choices in

underserved areas

-- Presence of retail venues that provide healthier

foods is associated with better nutrition

-- Greater availability of supermarkets was

associated with lower adolescent BMI scores

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Improve availability of mechanisms for

purchasing foods from farms

--Evidence supporting a direct link between

purchasing food from farms amp improved diet is

limited

--Two studies of initiatives to encourage

participation in farmersrsquo market showed

increased intention to eat more fruits amp

vegetables but no direct evidence

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Provide incentives for the production

distribution and procurement of foods from local

farms

--No evidence has been published to link local

food production amp health outcomes

--There is a current study exploring the potential

nutritional amp health benefits of eating locally

grown foods

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Restrict availability of less healthy foods amp

beverages in public service venues

--No peer-reviewed studies examined the impact

designed to restrict availability of less healthy

foods in public service venues

--21 states have policies that restrict the sale of

competitive foods in schools beyond USDA

regulations however no studies have evaluated

the impact of the policies

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Institute smaller portion size options in public

service venues

--Evidence is lacking to demonstrate effectiveness

of population-based interventions aimed at

reducing portion sizes in public service venues

--Evidence from clinical studies in laboratories

demonstrates decreasing portion sizes

decreases energy intake

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Limit advertisements of less healthy foods amp

beverages

--Little evidence is available regarding the impact

of restricting advertising on purchasing amp

consumption of less healthy foods

--Cross-sectional time-series studies of tobacco-

control efforts suggest an association between

advertising bans amp decreased tobacco

consumption

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Discourage consumption of sugar-sweetened

beverages

--One longitudinal study of a school-based

intervention among Native-American high school

students showed a substantial reduction in

sugar-sweetened beverages over a 3-year

period

--A RCT of a home-based intervention that

eliminated sugar-sweetened beverages showed

reduction in BMI scores

Recommended Community Strategies Strategies to encourage breastfeeding

Increase support for breastfeeding

--Evidence directly linking environmental

interventions that support breastfeeding with

obesity-related outcomes is lacking

--Epidemiologic studies indicate that breastfeeding

helps prevent pediatric obesity

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Require physical education in schools

--14 studies have demonstrated that school-based

PE was effective in increasing levels of physical

activity and improving physical fitness

--Minimum of 150 minwk in elementary schools

225 minwk in middle schools and high schools

throughout the school year as recommended by

NASPE

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Increase opportunities for extracurricular

physical activity

--Participation in after-school programs increased

studentsrsquo level of physical activity amp improved

obesity-related outcomes (improved CV fitness

reduced body fat)

--2 pilot studies providing extracurricular physical

activity showed increased levels of PA amp

decreased sedentary behavior

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Reduce screen time in public service venues

--A school-based RCT indicated that children who

reduced their television videotape amp video

game use had significant decrease in BMI tricep

skin fold thickness amp waist circumference

compared to controls

--Spending less time watching television is

associated with increased physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Improve access to outdoor recreational

facilities

--Review of 108 studies indicated that access to facilities

and programs for recreation near their homes amp time

spent outdoors correlated positively with increased

physical activity among childrenamp adults

--Perceptions that footpaths are safe for walking was

significantly associated with adults being classified as

physically active at a level sufficient for health benefits

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting

bicycling

--Longitudinal intervention studies have

demonstrated that improving bicycling

infrastructure is associated with increased

frequency of bicycling

--Cross-sectional studies indicated a significant

association between bicycling infrastructure amp

frequency of biking

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting walking

--Reviews of cross-sectional studies of

environmental correlates of physical activity amp

walking generally find a positive association

between infrastructure supportive of walking amp

physical activity

--Identifying amp creating safe routes to school

together with educational components

increased the number of students walking to

school

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Locating schools within easy walking

distance of residential areas

--Community-scale urban design amp land use policies amp

practices including locating schools stores workplaces

amp recreation areas close to residential areas are

effective in facilitating an increase in levels of physical

activity

--Majority of efforts to encourage walking to school involve

improving the routes rather than improving the location

of schools

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Improve access to public transportation

--Insufficient evidence exists to determine

effectiveness of transportation policies in

increasing the level of physical activity or

improving fitness

--1 study indicated that 29 of individuals who

walk to and from public transit achieve at least

30 minutes of daily physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Zone for mixed-use development

--Allows residential commercial institutional amp

other public land uses to be located in close

proximity to one another

--Studies using correlation analyses amp regression

models indicated that mixed land use was

associated with increased walking amp cycling

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance personal safety in areas where

persons are or could be physically active

--Cross-sectional studies have demonstrated a

negative relationship between crime rates andor

perceived safety amp physical activity in

neighborhoods

--Few intervention studies have evaluated the

impact of policies amp practices to improve

personal safety on physical activity

Geospatial Mapping Linking Urban

Environments to Health Risk

Measure association between environmental variables amp health risk factors

Assess relationships between variables at different levels of analysis

Used in conjunction with linear analyses

Our Community Environmental Model

of Obesity

Community Factors

Poverty

Crime

Grocery Quality

Restaurants

Parks

Sidewalks

Fast Food Outlets

Recreational

Facilities

Individual Factors

Dietary Intake

Physical Activity

Genetics

Family History

StressCoping

Eating Disorders

Psychological

Problems

Weight

Status

Chosen Neighborhoods

Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped

We then matched census-block groups within the income groups by population density and percentage of minority representation

One matched block group per income level was randomly selected

Prevalence of Obesity in

Block-Groups

0

5

10

15

20

25

30

35

40

45

50

Ag

e-a

dju

sted

Ob

esit

y P

rev

ale

nce

(

)

High-Income Low-Income

Age-standardized to the 1990 US Census

Density of Environmental Factors in the

Community Contributes to a ldquoToxicrdquo

Obesity Environment

0

2

4

6

8

10

12

14

16

18

Fast-food Convenience Store Bars

Den

sity

10

00

perso

ns

High-Income Low-Income

COMMUNITYrsquoS PERCEPTION OF SAFETY

0

5

10

15

20

25

30

35

40

Daytime Nighttime

Perc

en

t (

) F

eeli

ng

So

mew

hat

Safe

or

Un

safe

Low-Income High-Income

Percent Substandard (or worse) Housing

or Ground Conditions

of Residential Properties

0

10

20

30

Structural Grounds

Perc

en

t (

)

Low-Income High-Income

CONCLUSIONS

These data suggest that the higher

frequency of outlets providing

calorically-dense foods and alcohol may

contribute to greater obesity prevalence

in residents of low-income communities

More research is needed to thoroughly

document environmental determinants

of health and obesity

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

From 1994-1998 HUD randomly assigned

4498 women with children living in public

housing in high-poverty urban census

tracts to one of three groups (1) housing

vouchers redeemable only if they moved

to a low-poverty census tract (2)

unrestricted vouchers or (3) control group

(no vouchers)

Ludwig et al NEJM 201136516

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

10-12 year follow-up showed modest but

potentially important reductions in the

prevalence of extreme obesity amp diabetes in the

group moving from a neighborhood with high

poverty on one of low poverty compared to the

control group

No differences between the group receiving

traditional vouchers amp the control group

ldquoNeighborhoods matterrdquo

Ludwig et al NEJM 201136516

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance traffic safety in areas where

persons are or could be physically active

--Community-scale urban design amp land use policies to

promote physical activity including design components

to improve street lighting infrastructure projects to

increase safety of pedestrian street crossing and use of

traffic calming approaches such as speed humps amp

traffic circles are effective in increasing physical activity

--Both community-scale amp street-scale policies amp practices

are effective in increasing physical activity

Recommended Community Strategies Encourage Communities to Organize for Change

Participate in community coalitions or

partnerships to address obesity

--Little evidence is available to determine the

impact of community coalitions on obesity

prevention

--The presence of anti-smoking community

coalitions has been associated with lower rates

of tobacco consumption

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

$103 million awarded to 61 states and

communities including state amp local government

agencies tribes amp territories amp state amp local non-

profit organizations

To build capacity to implement changes for

community prevention efforts to ensure long-

term success

To implement evidence-based and practice-

based programs to improve health amp wellness

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Priority areas are

Tobacco-free living

Active living and healthy eating

Evidence-based quality clinical and other

preventive health services for prevention

and control of high blood pressure and

high cholesterol

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Applicants proposed specific activities in

line with their chosen priority areas in their

applications

Grantee activities will not be finalized until

plans are negotiated with CDC by early

2012

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Capacity-Building Award

The Confederated Tribes of The Chehalis

Reservation is receiving a $498663 planning

award to build capacity to support healthy

lifestyles among their tribal population of 1500

in Washington State

Work will target tobacco-free living active living

and healthy eating and quality clinical and other

healthy serviceswwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Implementation Award

Austin TX Dept of Health and Human Services

is receiving $1026158 to serve Travis County

(Austin) to expand efforts in tobacco-free living

active living and healthy eating quality clinical

and other preventive services social and

emotional wellness and healthy and safe

physical environmentswwwcdcgov1052011

Building sustainable healthy

communities Bottom line

Obesity is an environmental problem

Despite progress in genetic research public health advances only will occur when we take the environment seriously

Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment

Until we do this we will not make substantial progress in addressing the epidemic of obesity

Poston amp Foreyt Atherosclerosis 1999

Whatrsquos the best approach

Integrate all sectors of society into community

change interventions

Incorporate

Science amp Technology

Education

FamilyCommunity

Healthcare

Arts amp Entertainment

Law amp Politics

Commerce amp Trade

Sectors of Society

Arts amp Entertainm

ent

Commerce amp Trade

Education

FamilyCommunity

Healthcare

Law amp Politics

Science amp Technology

Project FIT rationale design and baseline characteristics of a school- and community-

based intervention to address physical activity and healthy eating among low-income

elementary school children

Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D

Oh HJ Orth J Randall S Mayfield K Holmes D

Source

Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu

Abstract

BACKGROUND

This paper describes Project FIT a collaboration between the public school system local

health systems physicians neighborhood associations businesses faith-based leaders

community agencies and university researchers to develop a multi-faceted approach to

promote physical activity and healthy eating toward the general goal of preventing and

reducing childhood obesity among children in Grand Rapids MI USA

METHODSDESIGN

There are four overall components to Project FIT school community social marketing and

school staff wellness - all that focus on 1) increasing access to safe and affordable physical

activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)

improving the affordability and availability of nutritious food in the neighborhoods surrounding

the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding

nutrition and physical activity among school staff parents and students 4) impacting the

culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging

dialogue among all community partners to leverage existing programs and introduce new

ones

Results of Lifestyle Interventions

Pattern of Weight Regain

Weight regain occurs steadily over 2-5 yrs

Long-term follow-ups of behavioral interventions show a reliable pattern of gradual regaining of lost weight

Long-term losses of ge 5 Kg are sustained in less than 20 of patients in behavioral treatment

Perri Foreyt amp Anton Preventing Weight

Regain After Weight Loss 2008

Results of Lifestyle Interventions

Pattern of Weight Regain

ldquoThe difficulty associated with

maintaining lost weight appears to

be the result of physiological

environmental and psychological

factors that combine to facilitate a

regaining of lost weight and an

abandonment of weight control

effortsrdquo

Perri Foreyt amp Anton 2008

Population-wide prevention of obesity

Small changes in diet and physical activity may make more sense than focusing on large behavioral changes

By cutting 100 calories a day adults can prevent weight gain

Hill et al Science 2003 Hill AJCN 2009

BENEFITS OF MODEST WEIGHT LOSS

ldquoSeveral studies demonstrate that small losseshelliphelp reduce obesity-related co-morbidities and that improvements in these risk factors persist with maintenance of these modest weight lossesrdquo

Institute of Medicine 1995

- Glucose levels - HDL cholesterol levels

- Insulin levels - LDL cholesterol levels

- Glycated hemoglobin - Blood pressure

- Triglyceride levels - Quality of life levels

Stigmatization amp Discrimination

Societal beliefs that weight can be controlled thereby suggestive of character deficits (lack of willpower laziness and emotional problems)

Negative attitudes

ldquoLast safe prejudicerdquo in US society

Rand CSW Macgregor AMC South Med J 1990

DISCRIMINATION

THE PAIN OF OBESITY

Former severely obese patients

100 preferred to be deaf dyslexic

diabetic or have heart disease or bad

acne than to be obese again

Leg amputation was preferred by

915 and blindness by 894

100 preferred to be a normal weight

person rather than a severely obese

multi-millionaire Rand CSW Macgregor AMC Int J Obes 199115577ndash579

Psychosocial Burden of Obesity

Obese individuals often feel misunderstood neglected and rejected

Obese individuals have low employment prospects and are denied educational vocational and advancement opportunities

Significantly poorer quality of life

van Hout GCM van Oudheusden I amp van Heck GL Obes Surg 2004

A Healthy Lifestyle is All About

Balance

Healthy Diet

Healthy Physical Activity

Building Sustainable Healthy

Communities

Healthy Lifestyle

Building Sustainable Healthy

Communities

Healthy Lifestyle

UNFORTUNATELYhellip

Big Texan Steak Ranch

Amarillo Texas

72-oz Steak FREE if eaten within 1 hour

AVERAGE ADULT AMERICAN MAN

Height 5rsquo 8rdquo

Weight 195 lbs

Waist 397 in

BMI 284

CDC 2011

AVERAGE ADULT AMERICAN WOMAN

Height 5rsquo3rdquo

Weight 165 lbs

Waist 370 in

BMI 261

CDC 2011

Miss America

2008

Kirsten Haglund

BMI 1629

Eliana Ramos

Age 18

Height 5rsquo9rdquo

29th OLYMPIAD

BEIJING CHINA

US wrestling team captain Daniel

Cormier (2115 lbs) hospitalized for

kidney failure as result of

dehydration related to cutting weight

(did not compete)

US boxer Gary Russell was found

unconscious 4 days before his

Olympic bout due to cutting weight

(did not compete)

29th OLYMPIAD

BEIJING CHINA

Michael Phelps

8 Gold Medals SwimmingAge 23

Height 6rsquo4rdquo

Weight 195 lbs

BMI 2374

Daily Food Intake 10375 KCAL

(15 PRO 58 CHO 27 FAT)

Exercise 30 hrswk

2005 USDA FOOD PYRAMID

ldquoThe food pyramid

is too complicated

and has too many

messagesrdquo

Robert Post PhD USDA Deputy

Director 2011

2005 USDA FOOD PYRAMID

ldquoItrsquos going to be hard not to do

better than the current pyramid

which basically conveys no

useful informationrdquo

Walter C Willett MD

Chairman Department of Nutrition

Harvard School of Public Health

2011 USDA MY PLATE

ldquoWe are all

bombarded with so

many dietary

messages that it is

hard to find time to

sort through all this

informationrdquo

Michelle Obama 2011

Dietary Guidelines for Americans

2010 Two Primary Concepts

Maintain calorie balance over time to

achieve and maintain a healthy weight

Focus on consuming nutrient-dense foods

and beverages

Dietary Guidelines for Americans 2010

Efficacy-based comparative dietary guidelines

Carb Fat Pro

Mediterranean Diet 45-55 25-35 20

IOM Dietary Ref Intakes 45-65 25-35 15

NCEP-ATPIII 50-60 25-35 15

Am Dietetic Assoc 45-65 20-35 15

PARADOX OF INCREASING OBESITY

PREVALENCE

bull Focus on healthy eating and physical

activity

bull Awareness of dangers of obesity buthellip

bull Obesity prevalence continues to rise

bull Work amp commuting demands

bull Little time to exercise

bull Little time to prepare food

bull Availability of high-fatcalorie foods

Rationale for community-based interventions

bull Increases in obesity prevalence due to genes

bull Increased calories (eg 200 Kcalday

over 10 years)

bull Increased portion sizes (eg 22 oz

steaks and 44 oz sodas)

bull Western diets in developing nations

increase risk of obesity

READINESS TO CHANGE

ldquoHabit is habit and not to be

flung out of the window but

coaxed downstairs a step at a

timerdquo

Mark Twain

Long-Term Weight Maintenance

National Weight Control Registry (N=10000)

Survey of 3000 members who have been in the

Registry for at least 10 years

Starting weight = 224 lbs Average weight loss=69

lbs

At 5 years participants had maintained an average

weight loss=52 lbs

At 10 years participants had maintained an average

weight loss=51 lbs

Thomas Bond Phelan et al TOS 2011

Long-Term Weight Maintenance

Weight Maintainers report that they usually

Track their food intake

Count calories or fat grams

Follow a low-calorie low fat diet (1800 caloriesday

less than 30 of calories from fat

Eat breakfast regularly

Limit the amount they eat out (about 3 timesweek

eat fast food less than onceweek)

Thomas Bond Phelan et al TOS 2011

Long-Term Weight Maintenance

Weight Maintainers report that they usually

Eat similar food regularly

Donrsquot splurge much on holidays amp special occasions

Walk about one hourday

Watch less than 10 hours of TV a week

Weigh themselves at least once a week

Thomas Bond Phelan et al TOS 2011

LONG-TERM WEIGHT MAINTENANCE

Continued consumption of a low-

calorie diet with moderate fat intake

Limited fast food

High levels of physical activity

Phalen et al Obesity 2006 14 710-716

LONG-TERM WEIGHT MAINTENANCE

Daily weighing improved

maintenance of weight loss

particularly when delivered

face to face

Wing et al NEJM 2006 3551563-1571

Most Promising Strategies For

Preventing Weight Regain

Providing multi-component

programs with ongoing

professional contacts

Physical activityexercise

Portion controlmeal replacements

Extending treatment through

weekly or bi-weekly sessions

Pharmacotherapy

Perri Foreyt amp Anton Preventing Weight Regain After Weight Loss 2008

Most Promising Strategies For

Preventing Weight Regain

Extended treatments have shown

promise in promoting adherence to

the behaviors required for the long-

term maintenance of weight loss

Continuous care approach focused

on reasonable long-term objectives

appears appropriate for most

patients

Perri Foreyt amp Anton Preventing Weight Regain After Weight

Loss 2008

An Example of a successful long-term

intervention

The Look AHEAD Study

Does Weight Loss Reduce

Cardiovascular Disease and Death in

Overweight Individuals with Diabetes

bull Action for HEAlth in Diabetes

bull Objective to examine in overweight

persons with Type 2 Diabetes the long-

term effects of an intensive lifestyle

intervention program compared to

diabetes education and support

bull 16 Centers

bull 5145 overweight volunteers with

diabetes

Look AHEAD

Look AHEAD

Primary End Point Composite

bull Cardiovascular death (including fatal

myocardial infarction and stroke)

bull Non-fatal myocardial infarction

bull Non-fatal stroke

Winston-Salem

Baltimore

Philadelphia

New York

Providence

Boston

Clinical Site Coordinating Center

Clinical Sites

Seattle

Los Angeles

San AntonioHouston

Baton Rouge

Minneapolis

Memphis

Birmingham

Pittsburgh

Denver

Phoenix

Look AHEADParticipants

101100Baseline weight (kg)

589586Age (years)

9496Attended 1 year exam

360359Baseline BMI

1514Insulin Users

3737Minority

6059Women

(N=2574)(N=2630)

DSELifestyle

p lt 0004

Look AHEAD

Study Interventions

bull Diabetes support and education - DSE (control group)

bull Lifestyle intervention ndash ILI (treatment group)

Look AHEAD

Lifestyle Intervention

Goals

bull 7 weight loss for the group (10

for individual)

bull 175 minutes of moderate intensity

activity

Look AHEAD

Lifestyle Intervention

bull Diet

ndash ADA NCEP (lt 30 fat lt 10 sat fat

gt15 protein)

ndash 1200-1500 (if weight lt250lbs)

ndash 1500-1800 (if weight gt250lbs)

ndash During first 4 weeks to 4 months portion

control (liquid meal replacements or

structured meal plan)

Look AHEAD

Lifestyle Intervention

bull Physical Activity

ndash unsupervised

ndash 175 minutes moderate intensityweek

ndash 5 daysweek

ndash walking

Weight Loss at 1-Year

-9

ILI 0

-1

-2

-3

-4

-5

-6

-7

-8

DSE

p lt 00001

W

eig

ht

Chan

ge

86

07

The Look AHEAD Research Group Diabetes Care 2007

Reduction in Initial Weight by Gender

N=872

N=1229N=1197

N=830

-12

-10

-8

-6

-4

-2

0

0 2 4 6 8 10 12

Months

R

ed

uctio

n in

In

itia

l W

eig

ht

Men

Women

Plt0001

The Look AHEAD Research Group Diabetes Care 2007

Fitness Change () at 1-Year

0

5

10

15

20

25

Mean

Fitness C

hange

Unadjusted

Plt0001Adjusted for 1 Year

Weight Change Plt0001

58

209

108

159

DSE ILI ILIDSE

The Look AHEAD Research Group Diabetes Care 2007

1-Year Changes in Markers of

Diabetes Control

Markers of Diabetes

Control ILI DSE P-value

Hemoglobin A1c () BL

Hemoglobin A1c () Y1

Y1 ndash Baseline

725

661

-064

729

715

-014

026

lt0001

lt0001

Fasting glucose (mgdl) BL

Fasting glucose (mgdl) Y1

Y1 ndash Baseline

1519

1304

-215

1536

1464

-72

021

lt0001

lt0001

Diabetes medications BL

Diabetes medications Y1

Y1 ndash Baseline

865

786

-78

865

887

22

093

lt0001

lt0001

1-Year Changes in Markers of

Blood Pressure ControlMarkers of Blood Pressure

Control ILI DSE P-value

Systolic BP (mmHg) BL

Systolic BP (mmHg) Y1

Y1 ndash Baseline

1282

1214

-68

1294

1266

-28

026

lt0001

lt0001

Diastolic BP (mmHg) BL

Diastolic BP (mmHg) Y1

Y1 ndash Baseline

699

670

-30

704

686

-18

011

lt0001

lt0001

Antihypertensive medications BL

Antihypertensive medications Y1

Y1 ndash Baseline

753

752

-01

737

759

22

023

054

002

1-Year Changes in Markers of Lipid

Control

Markers of Lipid Control ILI DSE P-value

LDL-cholesterol (mgdl) BL

LDL-cholesterol (mgdl) Y1

Y1 ndash Baseline

1122

1070

-52

1124

1067

-57

078

074

049

HDL-cholesterol (mgdl) BL

HDL-cholesterol (mgdl) Y1

Y1 ndash Baseline

435

469

34

436

449

14

080

lt0001

lt0001

Triglycerides (mgdl) BL

Triglycerides (mgdl) Y1

Y1 ndash Baseline

1828

1525

-303

1800

1654

-146

038

lt0001

lt0001

Lipid lowering medications BL

Lipid lowering medications Y1

Y1 ndash Baseline

494

530

37

484

578

94

052

lt0001

lt0001

1-Year Changes in Percent of Participants

Meeting ADA Goals

ADA Goal ILI DSE P-value

Hemoglobin A1c lt 7 BL

Hemoglobin A1c lt 7 Y1

Y1 ndash Baseline

463

727

264

454

508

54

050

lt0001

lt0001

Blood pressure lt 13080 mmHg BL

Blood pressure lt 13080 mmHg Y1

Y1 ndash Baseline

535

686

151

499

570

70

001

lt0001

lt0001

LDL-cholesterol lt 100 mgdl BL

LDL-cholesterol lt 100 mgdl Y1

Y1 ndash Baseline

371

438

67

369

449

80

087

045

034

All three goals BL

All three goals Y1

Y1 ndash Baseline

108

236

128

95

160

65

013

lt0001

lt0001

Mean Changes in Weight Fitness amp BP

Averaged Over Four Years

DSE

Mean

ILI

Mean

P-value

Weight Loss

( initial wt)

-088 -615 lt 00001

Fitness

( METS)

196 1274 lt00001

HbA1c -009 -036 lt 00001

SBP (mm Hg) -297 -533 lt 00001

DBP (mm Hg) -248 -292 0012

Look AHEAD Research Group Arch Int Med 2010

Mean Changes in Lipid Profile

Averaged Over Four Years

DSE

Mean

ILI

Mean

P-value

HDL (mgdl) 197 367 lt00001

TG (mgdl) -1975 -2556 00006

LDL (mgdl) -1284 -1127 0009

LDL (mgdl)

(Adjusting for

medication use)

-922 -875 042

Look AHEAD Research Group Arch Int Med 2010

Percent () Completing Outcome

Measures at Years 1-4

Intervention Group

(ILI)

Year 1 971

Year 2 949

Year 3 940

Year 4 941

Comparison Group

(DSE)

Year 1 957

Year 2 935

Year 3 938

Year 4 931

Look AHEAD Summary

ILI had significantly greater improvements than DSE in all CVD risk factors averaged across 4 years (except LDL-C)

There may be long-term beneficial effects from this 4-year period in which ILI subjects have been exposed to lower CVD risk factors

Longer follow-ups will determine whether these lowered CVD risk factors can be maintained amp whether lifestyle intervention has positive effects on CVD morbidity amp mortality

Mary J

Female

White

56 years old at start of Look AHEAD

study

Past Medical History Type 2 diabetes

overweight diverticulosis arthritis

sleep apnea back pain

Mary J

bullLong term strugglesbull Helping youngest daughter with

personal issues and children

bull Rotator cuff problems

bull Degenerative disks in back

bull Rheumatoid arthritis

bull Diabetes

bull Physically demanding job

bull Financial struggles

Pounds

Years

82007 grandkids enter pre-school

Catherine L

Female

White

47 years old at start of Look AHEAD

study

Past Medical History Type 2 diabetes

overweight high blood pressure

hypothyroidism back pain

Catherine L

Long term struggles

bull Motherrsquos declining health and death

bull Multiple serious injuries

bull Sudden death of sister

bull Death of step-father

bull Declining economy

bull Children living at home

Pounds

Years

Realistic Management Goals

5-10 weight loss

Health energy and fitness

Well-being and self-esteem

Mood and appearance

Functional and recreational

activity

Key Elements

Focus on health and energy

Food and physical activity diaries

Gradual increase in physical activity

Gradual reduction in dietary fat

No feelings of food deprivation

Social support groups

Recommended Strategies for Building

Sustainable Healthy Communities

Overview from USA

Promote the availability of affordable healthy

food and beverages

Support healthy food and beverage choices

Encourage breastfeeding

Encourage physical activity or limit sedentary

activity among children amp youth

Create safe communities that support physical

activity

Encourage communities to organize for change

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Increase the availability of healthier food and

beverage choices in public service venues (eg

schools city amp county buildings etc)

--Insufficient evidence in school-based programs

--Associations suggest availability amp increased

consumption

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve availability of affordable healthier

food amp beverage choices in public service

venues

--Reducing the cost of healthier foods

increases their purchase

--Providing coupons redeemable for

healthier foods increases their purchase

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve geographic availability of

supermarkets in underserved areas

-- Greater access to nearby supermarkets is

associated with healthier eating behaviors

-- Increasing the number of supermarkets in

underserved neighborhoods increased

real estate values increased economic

activity amp employment amp resulted in lower

food prices

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Provide incentives to food retailers to locate in

andor offer healthier food choices in

underserved areas

-- Presence of retail venues that provide healthier

foods is associated with better nutrition

-- Greater availability of supermarkets was

associated with lower adolescent BMI scores

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Improve availability of mechanisms for

purchasing foods from farms

--Evidence supporting a direct link between

purchasing food from farms amp improved diet is

limited

--Two studies of initiatives to encourage

participation in farmersrsquo market showed

increased intention to eat more fruits amp

vegetables but no direct evidence

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Provide incentives for the production

distribution and procurement of foods from local

farms

--No evidence has been published to link local

food production amp health outcomes

--There is a current study exploring the potential

nutritional amp health benefits of eating locally

grown foods

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Restrict availability of less healthy foods amp

beverages in public service venues

--No peer-reviewed studies examined the impact

designed to restrict availability of less healthy

foods in public service venues

--21 states have policies that restrict the sale of

competitive foods in schools beyond USDA

regulations however no studies have evaluated

the impact of the policies

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Institute smaller portion size options in public

service venues

--Evidence is lacking to demonstrate effectiveness

of population-based interventions aimed at

reducing portion sizes in public service venues

--Evidence from clinical studies in laboratories

demonstrates decreasing portion sizes

decreases energy intake

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Limit advertisements of less healthy foods amp

beverages

--Little evidence is available regarding the impact

of restricting advertising on purchasing amp

consumption of less healthy foods

--Cross-sectional time-series studies of tobacco-

control efforts suggest an association between

advertising bans amp decreased tobacco

consumption

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Discourage consumption of sugar-sweetened

beverages

--One longitudinal study of a school-based

intervention among Native-American high school

students showed a substantial reduction in

sugar-sweetened beverages over a 3-year

period

--A RCT of a home-based intervention that

eliminated sugar-sweetened beverages showed

reduction in BMI scores

Recommended Community Strategies Strategies to encourage breastfeeding

Increase support for breastfeeding

--Evidence directly linking environmental

interventions that support breastfeeding with

obesity-related outcomes is lacking

--Epidemiologic studies indicate that breastfeeding

helps prevent pediatric obesity

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Require physical education in schools

--14 studies have demonstrated that school-based

PE was effective in increasing levels of physical

activity and improving physical fitness

--Minimum of 150 minwk in elementary schools

225 minwk in middle schools and high schools

throughout the school year as recommended by

NASPE

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Increase opportunities for extracurricular

physical activity

--Participation in after-school programs increased

studentsrsquo level of physical activity amp improved

obesity-related outcomes (improved CV fitness

reduced body fat)

--2 pilot studies providing extracurricular physical

activity showed increased levels of PA amp

decreased sedentary behavior

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Reduce screen time in public service venues

--A school-based RCT indicated that children who

reduced their television videotape amp video

game use had significant decrease in BMI tricep

skin fold thickness amp waist circumference

compared to controls

--Spending less time watching television is

associated with increased physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Improve access to outdoor recreational

facilities

--Review of 108 studies indicated that access to facilities

and programs for recreation near their homes amp time

spent outdoors correlated positively with increased

physical activity among childrenamp adults

--Perceptions that footpaths are safe for walking was

significantly associated with adults being classified as

physically active at a level sufficient for health benefits

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting

bicycling

--Longitudinal intervention studies have

demonstrated that improving bicycling

infrastructure is associated with increased

frequency of bicycling

--Cross-sectional studies indicated a significant

association between bicycling infrastructure amp

frequency of biking

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting walking

--Reviews of cross-sectional studies of

environmental correlates of physical activity amp

walking generally find a positive association

between infrastructure supportive of walking amp

physical activity

--Identifying amp creating safe routes to school

together with educational components

increased the number of students walking to

school

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Locating schools within easy walking

distance of residential areas

--Community-scale urban design amp land use policies amp

practices including locating schools stores workplaces

amp recreation areas close to residential areas are

effective in facilitating an increase in levels of physical

activity

--Majority of efforts to encourage walking to school involve

improving the routes rather than improving the location

of schools

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Improve access to public transportation

--Insufficient evidence exists to determine

effectiveness of transportation policies in

increasing the level of physical activity or

improving fitness

--1 study indicated that 29 of individuals who

walk to and from public transit achieve at least

30 minutes of daily physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Zone for mixed-use development

--Allows residential commercial institutional amp

other public land uses to be located in close

proximity to one another

--Studies using correlation analyses amp regression

models indicated that mixed land use was

associated with increased walking amp cycling

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance personal safety in areas where

persons are or could be physically active

--Cross-sectional studies have demonstrated a

negative relationship between crime rates andor

perceived safety amp physical activity in

neighborhoods

--Few intervention studies have evaluated the

impact of policies amp practices to improve

personal safety on physical activity

Geospatial Mapping Linking Urban

Environments to Health Risk

Measure association between environmental variables amp health risk factors

Assess relationships between variables at different levels of analysis

Used in conjunction with linear analyses

Our Community Environmental Model

of Obesity

Community Factors

Poverty

Crime

Grocery Quality

Restaurants

Parks

Sidewalks

Fast Food Outlets

Recreational

Facilities

Individual Factors

Dietary Intake

Physical Activity

Genetics

Family History

StressCoping

Eating Disorders

Psychological

Problems

Weight

Status

Chosen Neighborhoods

Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped

We then matched census-block groups within the income groups by population density and percentage of minority representation

One matched block group per income level was randomly selected

Prevalence of Obesity in

Block-Groups

0

5

10

15

20

25

30

35

40

45

50

Ag

e-a

dju

sted

Ob

esit

y P

rev

ale

nce

(

)

High-Income Low-Income

Age-standardized to the 1990 US Census

Density of Environmental Factors in the

Community Contributes to a ldquoToxicrdquo

Obesity Environment

0

2

4

6

8

10

12

14

16

18

Fast-food Convenience Store Bars

Den

sity

10

00

perso

ns

High-Income Low-Income

COMMUNITYrsquoS PERCEPTION OF SAFETY

0

5

10

15

20

25

30

35

40

Daytime Nighttime

Perc

en

t (

) F

eeli

ng

So

mew

hat

Safe

or

Un

safe

Low-Income High-Income

Percent Substandard (or worse) Housing

or Ground Conditions

of Residential Properties

0

10

20

30

Structural Grounds

Perc

en

t (

)

Low-Income High-Income

CONCLUSIONS

These data suggest that the higher

frequency of outlets providing

calorically-dense foods and alcohol may

contribute to greater obesity prevalence

in residents of low-income communities

More research is needed to thoroughly

document environmental determinants

of health and obesity

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

From 1994-1998 HUD randomly assigned

4498 women with children living in public

housing in high-poverty urban census

tracts to one of three groups (1) housing

vouchers redeemable only if they moved

to a low-poverty census tract (2)

unrestricted vouchers or (3) control group

(no vouchers)

Ludwig et al NEJM 201136516

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

10-12 year follow-up showed modest but

potentially important reductions in the

prevalence of extreme obesity amp diabetes in the

group moving from a neighborhood with high

poverty on one of low poverty compared to the

control group

No differences between the group receiving

traditional vouchers amp the control group

ldquoNeighborhoods matterrdquo

Ludwig et al NEJM 201136516

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance traffic safety in areas where

persons are or could be physically active

--Community-scale urban design amp land use policies to

promote physical activity including design components

to improve street lighting infrastructure projects to

increase safety of pedestrian street crossing and use of

traffic calming approaches such as speed humps amp

traffic circles are effective in increasing physical activity

--Both community-scale amp street-scale policies amp practices

are effective in increasing physical activity

Recommended Community Strategies Encourage Communities to Organize for Change

Participate in community coalitions or

partnerships to address obesity

--Little evidence is available to determine the

impact of community coalitions on obesity

prevention

--The presence of anti-smoking community

coalitions has been associated with lower rates

of tobacco consumption

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

$103 million awarded to 61 states and

communities including state amp local government

agencies tribes amp territories amp state amp local non-

profit organizations

To build capacity to implement changes for

community prevention efforts to ensure long-

term success

To implement evidence-based and practice-

based programs to improve health amp wellness

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Priority areas are

Tobacco-free living

Active living and healthy eating

Evidence-based quality clinical and other

preventive health services for prevention

and control of high blood pressure and

high cholesterol

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Applicants proposed specific activities in

line with their chosen priority areas in their

applications

Grantee activities will not be finalized until

plans are negotiated with CDC by early

2012

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Capacity-Building Award

The Confederated Tribes of The Chehalis

Reservation is receiving a $498663 planning

award to build capacity to support healthy

lifestyles among their tribal population of 1500

in Washington State

Work will target tobacco-free living active living

and healthy eating and quality clinical and other

healthy serviceswwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Implementation Award

Austin TX Dept of Health and Human Services

is receiving $1026158 to serve Travis County

(Austin) to expand efforts in tobacco-free living

active living and healthy eating quality clinical

and other preventive services social and

emotional wellness and healthy and safe

physical environmentswwwcdcgov1052011

Building sustainable healthy

communities Bottom line

Obesity is an environmental problem

Despite progress in genetic research public health advances only will occur when we take the environment seriously

Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment

Until we do this we will not make substantial progress in addressing the epidemic of obesity

Poston amp Foreyt Atherosclerosis 1999

Whatrsquos the best approach

Integrate all sectors of society into community

change interventions

Incorporate

Science amp Technology

Education

FamilyCommunity

Healthcare

Arts amp Entertainment

Law amp Politics

Commerce amp Trade

Sectors of Society

Arts amp Entertainm

ent

Commerce amp Trade

Education

FamilyCommunity

Healthcare

Law amp Politics

Science amp Technology

Project FIT rationale design and baseline characteristics of a school- and community-

based intervention to address physical activity and healthy eating among low-income

elementary school children

Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D

Oh HJ Orth J Randall S Mayfield K Holmes D

Source

Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu

Abstract

BACKGROUND

This paper describes Project FIT a collaboration between the public school system local

health systems physicians neighborhood associations businesses faith-based leaders

community agencies and university researchers to develop a multi-faceted approach to

promote physical activity and healthy eating toward the general goal of preventing and

reducing childhood obesity among children in Grand Rapids MI USA

METHODSDESIGN

There are four overall components to Project FIT school community social marketing and

school staff wellness - all that focus on 1) increasing access to safe and affordable physical

activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)

improving the affordability and availability of nutritious food in the neighborhoods surrounding

the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding

nutrition and physical activity among school staff parents and students 4) impacting the

culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging

dialogue among all community partners to leverage existing programs and introduce new

ones

Results of Lifestyle Interventions

Pattern of Weight Regain

ldquoThe difficulty associated with

maintaining lost weight appears to

be the result of physiological

environmental and psychological

factors that combine to facilitate a

regaining of lost weight and an

abandonment of weight control

effortsrdquo

Perri Foreyt amp Anton 2008

Population-wide prevention of obesity

Small changes in diet and physical activity may make more sense than focusing on large behavioral changes

By cutting 100 calories a day adults can prevent weight gain

Hill et al Science 2003 Hill AJCN 2009

BENEFITS OF MODEST WEIGHT LOSS

ldquoSeveral studies demonstrate that small losseshelliphelp reduce obesity-related co-morbidities and that improvements in these risk factors persist with maintenance of these modest weight lossesrdquo

Institute of Medicine 1995

- Glucose levels - HDL cholesterol levels

- Insulin levels - LDL cholesterol levels

- Glycated hemoglobin - Blood pressure

- Triglyceride levels - Quality of life levels

Stigmatization amp Discrimination

Societal beliefs that weight can be controlled thereby suggestive of character deficits (lack of willpower laziness and emotional problems)

Negative attitudes

ldquoLast safe prejudicerdquo in US society

Rand CSW Macgregor AMC South Med J 1990

DISCRIMINATION

THE PAIN OF OBESITY

Former severely obese patients

100 preferred to be deaf dyslexic

diabetic or have heart disease or bad

acne than to be obese again

Leg amputation was preferred by

915 and blindness by 894

100 preferred to be a normal weight

person rather than a severely obese

multi-millionaire Rand CSW Macgregor AMC Int J Obes 199115577ndash579

Psychosocial Burden of Obesity

Obese individuals often feel misunderstood neglected and rejected

Obese individuals have low employment prospects and are denied educational vocational and advancement opportunities

Significantly poorer quality of life

van Hout GCM van Oudheusden I amp van Heck GL Obes Surg 2004

A Healthy Lifestyle is All About

Balance

Healthy Diet

Healthy Physical Activity

Building Sustainable Healthy

Communities

Healthy Lifestyle

Building Sustainable Healthy

Communities

Healthy Lifestyle

UNFORTUNATELYhellip

Big Texan Steak Ranch

Amarillo Texas

72-oz Steak FREE if eaten within 1 hour

AVERAGE ADULT AMERICAN MAN

Height 5rsquo 8rdquo

Weight 195 lbs

Waist 397 in

BMI 284

CDC 2011

AVERAGE ADULT AMERICAN WOMAN

Height 5rsquo3rdquo

Weight 165 lbs

Waist 370 in

BMI 261

CDC 2011

Miss America

2008

Kirsten Haglund

BMI 1629

Eliana Ramos

Age 18

Height 5rsquo9rdquo

29th OLYMPIAD

BEIJING CHINA

US wrestling team captain Daniel

Cormier (2115 lbs) hospitalized for

kidney failure as result of

dehydration related to cutting weight

(did not compete)

US boxer Gary Russell was found

unconscious 4 days before his

Olympic bout due to cutting weight

(did not compete)

29th OLYMPIAD

BEIJING CHINA

Michael Phelps

8 Gold Medals SwimmingAge 23

Height 6rsquo4rdquo

Weight 195 lbs

BMI 2374

Daily Food Intake 10375 KCAL

(15 PRO 58 CHO 27 FAT)

Exercise 30 hrswk

2005 USDA FOOD PYRAMID

ldquoThe food pyramid

is too complicated

and has too many

messagesrdquo

Robert Post PhD USDA Deputy

Director 2011

2005 USDA FOOD PYRAMID

ldquoItrsquos going to be hard not to do

better than the current pyramid

which basically conveys no

useful informationrdquo

Walter C Willett MD

Chairman Department of Nutrition

Harvard School of Public Health

2011 USDA MY PLATE

ldquoWe are all

bombarded with so

many dietary

messages that it is

hard to find time to

sort through all this

informationrdquo

Michelle Obama 2011

Dietary Guidelines for Americans

2010 Two Primary Concepts

Maintain calorie balance over time to

achieve and maintain a healthy weight

Focus on consuming nutrient-dense foods

and beverages

Dietary Guidelines for Americans 2010

Efficacy-based comparative dietary guidelines

Carb Fat Pro

Mediterranean Diet 45-55 25-35 20

IOM Dietary Ref Intakes 45-65 25-35 15

NCEP-ATPIII 50-60 25-35 15

Am Dietetic Assoc 45-65 20-35 15

PARADOX OF INCREASING OBESITY

PREVALENCE

bull Focus on healthy eating and physical

activity

bull Awareness of dangers of obesity buthellip

bull Obesity prevalence continues to rise

bull Work amp commuting demands

bull Little time to exercise

bull Little time to prepare food

bull Availability of high-fatcalorie foods

Rationale for community-based interventions

bull Increases in obesity prevalence due to genes

bull Increased calories (eg 200 Kcalday

over 10 years)

bull Increased portion sizes (eg 22 oz

steaks and 44 oz sodas)

bull Western diets in developing nations

increase risk of obesity

READINESS TO CHANGE

ldquoHabit is habit and not to be

flung out of the window but

coaxed downstairs a step at a

timerdquo

Mark Twain

Long-Term Weight Maintenance

National Weight Control Registry (N=10000)

Survey of 3000 members who have been in the

Registry for at least 10 years

Starting weight = 224 lbs Average weight loss=69

lbs

At 5 years participants had maintained an average

weight loss=52 lbs

At 10 years participants had maintained an average

weight loss=51 lbs

Thomas Bond Phelan et al TOS 2011

Long-Term Weight Maintenance

Weight Maintainers report that they usually

Track their food intake

Count calories or fat grams

Follow a low-calorie low fat diet (1800 caloriesday

less than 30 of calories from fat

Eat breakfast regularly

Limit the amount they eat out (about 3 timesweek

eat fast food less than onceweek)

Thomas Bond Phelan et al TOS 2011

Long-Term Weight Maintenance

Weight Maintainers report that they usually

Eat similar food regularly

Donrsquot splurge much on holidays amp special occasions

Walk about one hourday

Watch less than 10 hours of TV a week

Weigh themselves at least once a week

Thomas Bond Phelan et al TOS 2011

LONG-TERM WEIGHT MAINTENANCE

Continued consumption of a low-

calorie diet with moderate fat intake

Limited fast food

High levels of physical activity

Phalen et al Obesity 2006 14 710-716

LONG-TERM WEIGHT MAINTENANCE

Daily weighing improved

maintenance of weight loss

particularly when delivered

face to face

Wing et al NEJM 2006 3551563-1571

Most Promising Strategies For

Preventing Weight Regain

Providing multi-component

programs with ongoing

professional contacts

Physical activityexercise

Portion controlmeal replacements

Extending treatment through

weekly or bi-weekly sessions

Pharmacotherapy

Perri Foreyt amp Anton Preventing Weight Regain After Weight Loss 2008

Most Promising Strategies For

Preventing Weight Regain

Extended treatments have shown

promise in promoting adherence to

the behaviors required for the long-

term maintenance of weight loss

Continuous care approach focused

on reasonable long-term objectives

appears appropriate for most

patients

Perri Foreyt amp Anton Preventing Weight Regain After Weight

Loss 2008

An Example of a successful long-term

intervention

The Look AHEAD Study

Does Weight Loss Reduce

Cardiovascular Disease and Death in

Overweight Individuals with Diabetes

bull Action for HEAlth in Diabetes

bull Objective to examine in overweight

persons with Type 2 Diabetes the long-

term effects of an intensive lifestyle

intervention program compared to

diabetes education and support

bull 16 Centers

bull 5145 overweight volunteers with

diabetes

Look AHEAD

Look AHEAD

Primary End Point Composite

bull Cardiovascular death (including fatal

myocardial infarction and stroke)

bull Non-fatal myocardial infarction

bull Non-fatal stroke

Winston-Salem

Baltimore

Philadelphia

New York

Providence

Boston

Clinical Site Coordinating Center

Clinical Sites

Seattle

Los Angeles

San AntonioHouston

Baton Rouge

Minneapolis

Memphis

Birmingham

Pittsburgh

Denver

Phoenix

Look AHEADParticipants

101100Baseline weight (kg)

589586Age (years)

9496Attended 1 year exam

360359Baseline BMI

1514Insulin Users

3737Minority

6059Women

(N=2574)(N=2630)

DSELifestyle

p lt 0004

Look AHEAD

Study Interventions

bull Diabetes support and education - DSE (control group)

bull Lifestyle intervention ndash ILI (treatment group)

Look AHEAD

Lifestyle Intervention

Goals

bull 7 weight loss for the group (10

for individual)

bull 175 minutes of moderate intensity

activity

Look AHEAD

Lifestyle Intervention

bull Diet

ndash ADA NCEP (lt 30 fat lt 10 sat fat

gt15 protein)

ndash 1200-1500 (if weight lt250lbs)

ndash 1500-1800 (if weight gt250lbs)

ndash During first 4 weeks to 4 months portion

control (liquid meal replacements or

structured meal plan)

Look AHEAD

Lifestyle Intervention

bull Physical Activity

ndash unsupervised

ndash 175 minutes moderate intensityweek

ndash 5 daysweek

ndash walking

Weight Loss at 1-Year

-9

ILI 0

-1

-2

-3

-4

-5

-6

-7

-8

DSE

p lt 00001

W

eig

ht

Chan

ge

86

07

The Look AHEAD Research Group Diabetes Care 2007

Reduction in Initial Weight by Gender

N=872

N=1229N=1197

N=830

-12

-10

-8

-6

-4

-2

0

0 2 4 6 8 10 12

Months

R

ed

uctio

n in

In

itia

l W

eig

ht

Men

Women

Plt0001

The Look AHEAD Research Group Diabetes Care 2007

Fitness Change () at 1-Year

0

5

10

15

20

25

Mean

Fitness C

hange

Unadjusted

Plt0001Adjusted for 1 Year

Weight Change Plt0001

58

209

108

159

DSE ILI ILIDSE

The Look AHEAD Research Group Diabetes Care 2007

1-Year Changes in Markers of

Diabetes Control

Markers of Diabetes

Control ILI DSE P-value

Hemoglobin A1c () BL

Hemoglobin A1c () Y1

Y1 ndash Baseline

725

661

-064

729

715

-014

026

lt0001

lt0001

Fasting glucose (mgdl) BL

Fasting glucose (mgdl) Y1

Y1 ndash Baseline

1519

1304

-215

1536

1464

-72

021

lt0001

lt0001

Diabetes medications BL

Diabetes medications Y1

Y1 ndash Baseline

865

786

-78

865

887

22

093

lt0001

lt0001

1-Year Changes in Markers of

Blood Pressure ControlMarkers of Blood Pressure

Control ILI DSE P-value

Systolic BP (mmHg) BL

Systolic BP (mmHg) Y1

Y1 ndash Baseline

1282

1214

-68

1294

1266

-28

026

lt0001

lt0001

Diastolic BP (mmHg) BL

Diastolic BP (mmHg) Y1

Y1 ndash Baseline

699

670

-30

704

686

-18

011

lt0001

lt0001

Antihypertensive medications BL

Antihypertensive medications Y1

Y1 ndash Baseline

753

752

-01

737

759

22

023

054

002

1-Year Changes in Markers of Lipid

Control

Markers of Lipid Control ILI DSE P-value

LDL-cholesterol (mgdl) BL

LDL-cholesterol (mgdl) Y1

Y1 ndash Baseline

1122

1070

-52

1124

1067

-57

078

074

049

HDL-cholesterol (mgdl) BL

HDL-cholesterol (mgdl) Y1

Y1 ndash Baseline

435

469

34

436

449

14

080

lt0001

lt0001

Triglycerides (mgdl) BL

Triglycerides (mgdl) Y1

Y1 ndash Baseline

1828

1525

-303

1800

1654

-146

038

lt0001

lt0001

Lipid lowering medications BL

Lipid lowering medications Y1

Y1 ndash Baseline

494

530

37

484

578

94

052

lt0001

lt0001

1-Year Changes in Percent of Participants

Meeting ADA Goals

ADA Goal ILI DSE P-value

Hemoglobin A1c lt 7 BL

Hemoglobin A1c lt 7 Y1

Y1 ndash Baseline

463

727

264

454

508

54

050

lt0001

lt0001

Blood pressure lt 13080 mmHg BL

Blood pressure lt 13080 mmHg Y1

Y1 ndash Baseline

535

686

151

499

570

70

001

lt0001

lt0001

LDL-cholesterol lt 100 mgdl BL

LDL-cholesterol lt 100 mgdl Y1

Y1 ndash Baseline

371

438

67

369

449

80

087

045

034

All three goals BL

All three goals Y1

Y1 ndash Baseline

108

236

128

95

160

65

013

lt0001

lt0001

Mean Changes in Weight Fitness amp BP

Averaged Over Four Years

DSE

Mean

ILI

Mean

P-value

Weight Loss

( initial wt)

-088 -615 lt 00001

Fitness

( METS)

196 1274 lt00001

HbA1c -009 -036 lt 00001

SBP (mm Hg) -297 -533 lt 00001

DBP (mm Hg) -248 -292 0012

Look AHEAD Research Group Arch Int Med 2010

Mean Changes in Lipid Profile

Averaged Over Four Years

DSE

Mean

ILI

Mean

P-value

HDL (mgdl) 197 367 lt00001

TG (mgdl) -1975 -2556 00006

LDL (mgdl) -1284 -1127 0009

LDL (mgdl)

(Adjusting for

medication use)

-922 -875 042

Look AHEAD Research Group Arch Int Med 2010

Percent () Completing Outcome

Measures at Years 1-4

Intervention Group

(ILI)

Year 1 971

Year 2 949

Year 3 940

Year 4 941

Comparison Group

(DSE)

Year 1 957

Year 2 935

Year 3 938

Year 4 931

Look AHEAD Summary

ILI had significantly greater improvements than DSE in all CVD risk factors averaged across 4 years (except LDL-C)

There may be long-term beneficial effects from this 4-year period in which ILI subjects have been exposed to lower CVD risk factors

Longer follow-ups will determine whether these lowered CVD risk factors can be maintained amp whether lifestyle intervention has positive effects on CVD morbidity amp mortality

Mary J

Female

White

56 years old at start of Look AHEAD

study

Past Medical History Type 2 diabetes

overweight diverticulosis arthritis

sleep apnea back pain

Mary J

bullLong term strugglesbull Helping youngest daughter with

personal issues and children

bull Rotator cuff problems

bull Degenerative disks in back

bull Rheumatoid arthritis

bull Diabetes

bull Physically demanding job

bull Financial struggles

Pounds

Years

82007 grandkids enter pre-school

Catherine L

Female

White

47 years old at start of Look AHEAD

study

Past Medical History Type 2 diabetes

overweight high blood pressure

hypothyroidism back pain

Catherine L

Long term struggles

bull Motherrsquos declining health and death

bull Multiple serious injuries

bull Sudden death of sister

bull Death of step-father

bull Declining economy

bull Children living at home

Pounds

Years

Realistic Management Goals

5-10 weight loss

Health energy and fitness

Well-being and self-esteem

Mood and appearance

Functional and recreational

activity

Key Elements

Focus on health and energy

Food and physical activity diaries

Gradual increase in physical activity

Gradual reduction in dietary fat

No feelings of food deprivation

Social support groups

Recommended Strategies for Building

Sustainable Healthy Communities

Overview from USA

Promote the availability of affordable healthy

food and beverages

Support healthy food and beverage choices

Encourage breastfeeding

Encourage physical activity or limit sedentary

activity among children amp youth

Create safe communities that support physical

activity

Encourage communities to organize for change

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Increase the availability of healthier food and

beverage choices in public service venues (eg

schools city amp county buildings etc)

--Insufficient evidence in school-based programs

--Associations suggest availability amp increased

consumption

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve availability of affordable healthier

food amp beverage choices in public service

venues

--Reducing the cost of healthier foods

increases their purchase

--Providing coupons redeemable for

healthier foods increases their purchase

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve geographic availability of

supermarkets in underserved areas

-- Greater access to nearby supermarkets is

associated with healthier eating behaviors

-- Increasing the number of supermarkets in

underserved neighborhoods increased

real estate values increased economic

activity amp employment amp resulted in lower

food prices

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Provide incentives to food retailers to locate in

andor offer healthier food choices in

underserved areas

-- Presence of retail venues that provide healthier

foods is associated with better nutrition

-- Greater availability of supermarkets was

associated with lower adolescent BMI scores

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Improve availability of mechanisms for

purchasing foods from farms

--Evidence supporting a direct link between

purchasing food from farms amp improved diet is

limited

--Two studies of initiatives to encourage

participation in farmersrsquo market showed

increased intention to eat more fruits amp

vegetables but no direct evidence

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Provide incentives for the production

distribution and procurement of foods from local

farms

--No evidence has been published to link local

food production amp health outcomes

--There is a current study exploring the potential

nutritional amp health benefits of eating locally

grown foods

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Restrict availability of less healthy foods amp

beverages in public service venues

--No peer-reviewed studies examined the impact

designed to restrict availability of less healthy

foods in public service venues

--21 states have policies that restrict the sale of

competitive foods in schools beyond USDA

regulations however no studies have evaluated

the impact of the policies

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Institute smaller portion size options in public

service venues

--Evidence is lacking to demonstrate effectiveness

of population-based interventions aimed at

reducing portion sizes in public service venues

--Evidence from clinical studies in laboratories

demonstrates decreasing portion sizes

decreases energy intake

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Limit advertisements of less healthy foods amp

beverages

--Little evidence is available regarding the impact

of restricting advertising on purchasing amp

consumption of less healthy foods

--Cross-sectional time-series studies of tobacco-

control efforts suggest an association between

advertising bans amp decreased tobacco

consumption

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Discourage consumption of sugar-sweetened

beverages

--One longitudinal study of a school-based

intervention among Native-American high school

students showed a substantial reduction in

sugar-sweetened beverages over a 3-year

period

--A RCT of a home-based intervention that

eliminated sugar-sweetened beverages showed

reduction in BMI scores

Recommended Community Strategies Strategies to encourage breastfeeding

Increase support for breastfeeding

--Evidence directly linking environmental

interventions that support breastfeeding with

obesity-related outcomes is lacking

--Epidemiologic studies indicate that breastfeeding

helps prevent pediatric obesity

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Require physical education in schools

--14 studies have demonstrated that school-based

PE was effective in increasing levels of physical

activity and improving physical fitness

--Minimum of 150 minwk in elementary schools

225 minwk in middle schools and high schools

throughout the school year as recommended by

NASPE

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Increase opportunities for extracurricular

physical activity

--Participation in after-school programs increased

studentsrsquo level of physical activity amp improved

obesity-related outcomes (improved CV fitness

reduced body fat)

--2 pilot studies providing extracurricular physical

activity showed increased levels of PA amp

decreased sedentary behavior

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Reduce screen time in public service venues

--A school-based RCT indicated that children who

reduced their television videotape amp video

game use had significant decrease in BMI tricep

skin fold thickness amp waist circumference

compared to controls

--Spending less time watching television is

associated with increased physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Improve access to outdoor recreational

facilities

--Review of 108 studies indicated that access to facilities

and programs for recreation near their homes amp time

spent outdoors correlated positively with increased

physical activity among childrenamp adults

--Perceptions that footpaths are safe for walking was

significantly associated with adults being classified as

physically active at a level sufficient for health benefits

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting

bicycling

--Longitudinal intervention studies have

demonstrated that improving bicycling

infrastructure is associated with increased

frequency of bicycling

--Cross-sectional studies indicated a significant

association between bicycling infrastructure amp

frequency of biking

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting walking

--Reviews of cross-sectional studies of

environmental correlates of physical activity amp

walking generally find a positive association

between infrastructure supportive of walking amp

physical activity

--Identifying amp creating safe routes to school

together with educational components

increased the number of students walking to

school

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Locating schools within easy walking

distance of residential areas

--Community-scale urban design amp land use policies amp

practices including locating schools stores workplaces

amp recreation areas close to residential areas are

effective in facilitating an increase in levels of physical

activity

--Majority of efforts to encourage walking to school involve

improving the routes rather than improving the location

of schools

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Improve access to public transportation

--Insufficient evidence exists to determine

effectiveness of transportation policies in

increasing the level of physical activity or

improving fitness

--1 study indicated that 29 of individuals who

walk to and from public transit achieve at least

30 minutes of daily physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Zone for mixed-use development

--Allows residential commercial institutional amp

other public land uses to be located in close

proximity to one another

--Studies using correlation analyses amp regression

models indicated that mixed land use was

associated with increased walking amp cycling

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance personal safety in areas where

persons are or could be physically active

--Cross-sectional studies have demonstrated a

negative relationship between crime rates andor

perceived safety amp physical activity in

neighborhoods

--Few intervention studies have evaluated the

impact of policies amp practices to improve

personal safety on physical activity

Geospatial Mapping Linking Urban

Environments to Health Risk

Measure association between environmental variables amp health risk factors

Assess relationships between variables at different levels of analysis

Used in conjunction with linear analyses

Our Community Environmental Model

of Obesity

Community Factors

Poverty

Crime

Grocery Quality

Restaurants

Parks

Sidewalks

Fast Food Outlets

Recreational

Facilities

Individual Factors

Dietary Intake

Physical Activity

Genetics

Family History

StressCoping

Eating Disorders

Psychological

Problems

Weight

Status

Chosen Neighborhoods

Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped

We then matched census-block groups within the income groups by population density and percentage of minority representation

One matched block group per income level was randomly selected

Prevalence of Obesity in

Block-Groups

0

5

10

15

20

25

30

35

40

45

50

Ag

e-a

dju

sted

Ob

esit

y P

rev

ale

nce

(

)

High-Income Low-Income

Age-standardized to the 1990 US Census

Density of Environmental Factors in the

Community Contributes to a ldquoToxicrdquo

Obesity Environment

0

2

4

6

8

10

12

14

16

18

Fast-food Convenience Store Bars

Den

sity

10

00

perso

ns

High-Income Low-Income

COMMUNITYrsquoS PERCEPTION OF SAFETY

0

5

10

15

20

25

30

35

40

Daytime Nighttime

Perc

en

t (

) F

eeli

ng

So

mew

hat

Safe

or

Un

safe

Low-Income High-Income

Percent Substandard (or worse) Housing

or Ground Conditions

of Residential Properties

0

10

20

30

Structural Grounds

Perc

en

t (

)

Low-Income High-Income

CONCLUSIONS

These data suggest that the higher

frequency of outlets providing

calorically-dense foods and alcohol may

contribute to greater obesity prevalence

in residents of low-income communities

More research is needed to thoroughly

document environmental determinants

of health and obesity

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

From 1994-1998 HUD randomly assigned

4498 women with children living in public

housing in high-poverty urban census

tracts to one of three groups (1) housing

vouchers redeemable only if they moved

to a low-poverty census tract (2)

unrestricted vouchers or (3) control group

(no vouchers)

Ludwig et al NEJM 201136516

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

10-12 year follow-up showed modest but

potentially important reductions in the

prevalence of extreme obesity amp diabetes in the

group moving from a neighborhood with high

poverty on one of low poverty compared to the

control group

No differences between the group receiving

traditional vouchers amp the control group

ldquoNeighborhoods matterrdquo

Ludwig et al NEJM 201136516

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance traffic safety in areas where

persons are or could be physically active

--Community-scale urban design amp land use policies to

promote physical activity including design components

to improve street lighting infrastructure projects to

increase safety of pedestrian street crossing and use of

traffic calming approaches such as speed humps amp

traffic circles are effective in increasing physical activity

--Both community-scale amp street-scale policies amp practices

are effective in increasing physical activity

Recommended Community Strategies Encourage Communities to Organize for Change

Participate in community coalitions or

partnerships to address obesity

--Little evidence is available to determine the

impact of community coalitions on obesity

prevention

--The presence of anti-smoking community

coalitions has been associated with lower rates

of tobacco consumption

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

$103 million awarded to 61 states and

communities including state amp local government

agencies tribes amp territories amp state amp local non-

profit organizations

To build capacity to implement changes for

community prevention efforts to ensure long-

term success

To implement evidence-based and practice-

based programs to improve health amp wellness

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Priority areas are

Tobacco-free living

Active living and healthy eating

Evidence-based quality clinical and other

preventive health services for prevention

and control of high blood pressure and

high cholesterol

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Applicants proposed specific activities in

line with their chosen priority areas in their

applications

Grantee activities will not be finalized until

plans are negotiated with CDC by early

2012

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Capacity-Building Award

The Confederated Tribes of The Chehalis

Reservation is receiving a $498663 planning

award to build capacity to support healthy

lifestyles among their tribal population of 1500

in Washington State

Work will target tobacco-free living active living

and healthy eating and quality clinical and other

healthy serviceswwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Implementation Award

Austin TX Dept of Health and Human Services

is receiving $1026158 to serve Travis County

(Austin) to expand efforts in tobacco-free living

active living and healthy eating quality clinical

and other preventive services social and

emotional wellness and healthy and safe

physical environmentswwwcdcgov1052011

Building sustainable healthy

communities Bottom line

Obesity is an environmental problem

Despite progress in genetic research public health advances only will occur when we take the environment seriously

Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment

Until we do this we will not make substantial progress in addressing the epidemic of obesity

Poston amp Foreyt Atherosclerosis 1999

Whatrsquos the best approach

Integrate all sectors of society into community

change interventions

Incorporate

Science amp Technology

Education

FamilyCommunity

Healthcare

Arts amp Entertainment

Law amp Politics

Commerce amp Trade

Sectors of Society

Arts amp Entertainm

ent

Commerce amp Trade

Education

FamilyCommunity

Healthcare

Law amp Politics

Science amp Technology

Project FIT rationale design and baseline characteristics of a school- and community-

based intervention to address physical activity and healthy eating among low-income

elementary school children

Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D

Oh HJ Orth J Randall S Mayfield K Holmes D

Source

Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu

Abstract

BACKGROUND

This paper describes Project FIT a collaboration between the public school system local

health systems physicians neighborhood associations businesses faith-based leaders

community agencies and university researchers to develop a multi-faceted approach to

promote physical activity and healthy eating toward the general goal of preventing and

reducing childhood obesity among children in Grand Rapids MI USA

METHODSDESIGN

There are four overall components to Project FIT school community social marketing and

school staff wellness - all that focus on 1) increasing access to safe and affordable physical

activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)

improving the affordability and availability of nutritious food in the neighborhoods surrounding

the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding

nutrition and physical activity among school staff parents and students 4) impacting the

culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging

dialogue among all community partners to leverage existing programs and introduce new

ones

Population-wide prevention of obesity

Small changes in diet and physical activity may make more sense than focusing on large behavioral changes

By cutting 100 calories a day adults can prevent weight gain

Hill et al Science 2003 Hill AJCN 2009

BENEFITS OF MODEST WEIGHT LOSS

ldquoSeveral studies demonstrate that small losseshelliphelp reduce obesity-related co-morbidities and that improvements in these risk factors persist with maintenance of these modest weight lossesrdquo

Institute of Medicine 1995

- Glucose levels - HDL cholesterol levels

- Insulin levels - LDL cholesterol levels

- Glycated hemoglobin - Blood pressure

- Triglyceride levels - Quality of life levels

Stigmatization amp Discrimination

Societal beliefs that weight can be controlled thereby suggestive of character deficits (lack of willpower laziness and emotional problems)

Negative attitudes

ldquoLast safe prejudicerdquo in US society

Rand CSW Macgregor AMC South Med J 1990

DISCRIMINATION

THE PAIN OF OBESITY

Former severely obese patients

100 preferred to be deaf dyslexic

diabetic or have heart disease or bad

acne than to be obese again

Leg amputation was preferred by

915 and blindness by 894

100 preferred to be a normal weight

person rather than a severely obese

multi-millionaire Rand CSW Macgregor AMC Int J Obes 199115577ndash579

Psychosocial Burden of Obesity

Obese individuals often feel misunderstood neglected and rejected

Obese individuals have low employment prospects and are denied educational vocational and advancement opportunities

Significantly poorer quality of life

van Hout GCM van Oudheusden I amp van Heck GL Obes Surg 2004

A Healthy Lifestyle is All About

Balance

Healthy Diet

Healthy Physical Activity

Building Sustainable Healthy

Communities

Healthy Lifestyle

Building Sustainable Healthy

Communities

Healthy Lifestyle

UNFORTUNATELYhellip

Big Texan Steak Ranch

Amarillo Texas

72-oz Steak FREE if eaten within 1 hour

AVERAGE ADULT AMERICAN MAN

Height 5rsquo 8rdquo

Weight 195 lbs

Waist 397 in

BMI 284

CDC 2011

AVERAGE ADULT AMERICAN WOMAN

Height 5rsquo3rdquo

Weight 165 lbs

Waist 370 in

BMI 261

CDC 2011

Miss America

2008

Kirsten Haglund

BMI 1629

Eliana Ramos

Age 18

Height 5rsquo9rdquo

29th OLYMPIAD

BEIJING CHINA

US wrestling team captain Daniel

Cormier (2115 lbs) hospitalized for

kidney failure as result of

dehydration related to cutting weight

(did not compete)

US boxer Gary Russell was found

unconscious 4 days before his

Olympic bout due to cutting weight

(did not compete)

29th OLYMPIAD

BEIJING CHINA

Michael Phelps

8 Gold Medals SwimmingAge 23

Height 6rsquo4rdquo

Weight 195 lbs

BMI 2374

Daily Food Intake 10375 KCAL

(15 PRO 58 CHO 27 FAT)

Exercise 30 hrswk

2005 USDA FOOD PYRAMID

ldquoThe food pyramid

is too complicated

and has too many

messagesrdquo

Robert Post PhD USDA Deputy

Director 2011

2005 USDA FOOD PYRAMID

ldquoItrsquos going to be hard not to do

better than the current pyramid

which basically conveys no

useful informationrdquo

Walter C Willett MD

Chairman Department of Nutrition

Harvard School of Public Health

2011 USDA MY PLATE

ldquoWe are all

bombarded with so

many dietary

messages that it is

hard to find time to

sort through all this

informationrdquo

Michelle Obama 2011

Dietary Guidelines for Americans

2010 Two Primary Concepts

Maintain calorie balance over time to

achieve and maintain a healthy weight

Focus on consuming nutrient-dense foods

and beverages

Dietary Guidelines for Americans 2010

Efficacy-based comparative dietary guidelines

Carb Fat Pro

Mediterranean Diet 45-55 25-35 20

IOM Dietary Ref Intakes 45-65 25-35 15

NCEP-ATPIII 50-60 25-35 15

Am Dietetic Assoc 45-65 20-35 15

PARADOX OF INCREASING OBESITY

PREVALENCE

bull Focus on healthy eating and physical

activity

bull Awareness of dangers of obesity buthellip

bull Obesity prevalence continues to rise

bull Work amp commuting demands

bull Little time to exercise

bull Little time to prepare food

bull Availability of high-fatcalorie foods

Rationale for community-based interventions

bull Increases in obesity prevalence due to genes

bull Increased calories (eg 200 Kcalday

over 10 years)

bull Increased portion sizes (eg 22 oz

steaks and 44 oz sodas)

bull Western diets in developing nations

increase risk of obesity

READINESS TO CHANGE

ldquoHabit is habit and not to be

flung out of the window but

coaxed downstairs a step at a

timerdquo

Mark Twain

Long-Term Weight Maintenance

National Weight Control Registry (N=10000)

Survey of 3000 members who have been in the

Registry for at least 10 years

Starting weight = 224 lbs Average weight loss=69

lbs

At 5 years participants had maintained an average

weight loss=52 lbs

At 10 years participants had maintained an average

weight loss=51 lbs

Thomas Bond Phelan et al TOS 2011

Long-Term Weight Maintenance

Weight Maintainers report that they usually

Track their food intake

Count calories or fat grams

Follow a low-calorie low fat diet (1800 caloriesday

less than 30 of calories from fat

Eat breakfast regularly

Limit the amount they eat out (about 3 timesweek

eat fast food less than onceweek)

Thomas Bond Phelan et al TOS 2011

Long-Term Weight Maintenance

Weight Maintainers report that they usually

Eat similar food regularly

Donrsquot splurge much on holidays amp special occasions

Walk about one hourday

Watch less than 10 hours of TV a week

Weigh themselves at least once a week

Thomas Bond Phelan et al TOS 2011

LONG-TERM WEIGHT MAINTENANCE

Continued consumption of a low-

calorie diet with moderate fat intake

Limited fast food

High levels of physical activity

Phalen et al Obesity 2006 14 710-716

LONG-TERM WEIGHT MAINTENANCE

Daily weighing improved

maintenance of weight loss

particularly when delivered

face to face

Wing et al NEJM 2006 3551563-1571

Most Promising Strategies For

Preventing Weight Regain

Providing multi-component

programs with ongoing

professional contacts

Physical activityexercise

Portion controlmeal replacements

Extending treatment through

weekly or bi-weekly sessions

Pharmacotherapy

Perri Foreyt amp Anton Preventing Weight Regain After Weight Loss 2008

Most Promising Strategies For

Preventing Weight Regain

Extended treatments have shown

promise in promoting adherence to

the behaviors required for the long-

term maintenance of weight loss

Continuous care approach focused

on reasonable long-term objectives

appears appropriate for most

patients

Perri Foreyt amp Anton Preventing Weight Regain After Weight

Loss 2008

An Example of a successful long-term

intervention

The Look AHEAD Study

Does Weight Loss Reduce

Cardiovascular Disease and Death in

Overweight Individuals with Diabetes

bull Action for HEAlth in Diabetes

bull Objective to examine in overweight

persons with Type 2 Diabetes the long-

term effects of an intensive lifestyle

intervention program compared to

diabetes education and support

bull 16 Centers

bull 5145 overweight volunteers with

diabetes

Look AHEAD

Look AHEAD

Primary End Point Composite

bull Cardiovascular death (including fatal

myocardial infarction and stroke)

bull Non-fatal myocardial infarction

bull Non-fatal stroke

Winston-Salem

Baltimore

Philadelphia

New York

Providence

Boston

Clinical Site Coordinating Center

Clinical Sites

Seattle

Los Angeles

San AntonioHouston

Baton Rouge

Minneapolis

Memphis

Birmingham

Pittsburgh

Denver

Phoenix

Look AHEADParticipants

101100Baseline weight (kg)

589586Age (years)

9496Attended 1 year exam

360359Baseline BMI

1514Insulin Users

3737Minority

6059Women

(N=2574)(N=2630)

DSELifestyle

p lt 0004

Look AHEAD

Study Interventions

bull Diabetes support and education - DSE (control group)

bull Lifestyle intervention ndash ILI (treatment group)

Look AHEAD

Lifestyle Intervention

Goals

bull 7 weight loss for the group (10

for individual)

bull 175 minutes of moderate intensity

activity

Look AHEAD

Lifestyle Intervention

bull Diet

ndash ADA NCEP (lt 30 fat lt 10 sat fat

gt15 protein)

ndash 1200-1500 (if weight lt250lbs)

ndash 1500-1800 (if weight gt250lbs)

ndash During first 4 weeks to 4 months portion

control (liquid meal replacements or

structured meal plan)

Look AHEAD

Lifestyle Intervention

bull Physical Activity

ndash unsupervised

ndash 175 minutes moderate intensityweek

ndash 5 daysweek

ndash walking

Weight Loss at 1-Year

-9

ILI 0

-1

-2

-3

-4

-5

-6

-7

-8

DSE

p lt 00001

W

eig

ht

Chan

ge

86

07

The Look AHEAD Research Group Diabetes Care 2007

Reduction in Initial Weight by Gender

N=872

N=1229N=1197

N=830

-12

-10

-8

-6

-4

-2

0

0 2 4 6 8 10 12

Months

R

ed

uctio

n in

In

itia

l W

eig

ht

Men

Women

Plt0001

The Look AHEAD Research Group Diabetes Care 2007

Fitness Change () at 1-Year

0

5

10

15

20

25

Mean

Fitness C

hange

Unadjusted

Plt0001Adjusted for 1 Year

Weight Change Plt0001

58

209

108

159

DSE ILI ILIDSE

The Look AHEAD Research Group Diabetes Care 2007

1-Year Changes in Markers of

Diabetes Control

Markers of Diabetes

Control ILI DSE P-value

Hemoglobin A1c () BL

Hemoglobin A1c () Y1

Y1 ndash Baseline

725

661

-064

729

715

-014

026

lt0001

lt0001

Fasting glucose (mgdl) BL

Fasting glucose (mgdl) Y1

Y1 ndash Baseline

1519

1304

-215

1536

1464

-72

021

lt0001

lt0001

Diabetes medications BL

Diabetes medications Y1

Y1 ndash Baseline

865

786

-78

865

887

22

093

lt0001

lt0001

1-Year Changes in Markers of

Blood Pressure ControlMarkers of Blood Pressure

Control ILI DSE P-value

Systolic BP (mmHg) BL

Systolic BP (mmHg) Y1

Y1 ndash Baseline

1282

1214

-68

1294

1266

-28

026

lt0001

lt0001

Diastolic BP (mmHg) BL

Diastolic BP (mmHg) Y1

Y1 ndash Baseline

699

670

-30

704

686

-18

011

lt0001

lt0001

Antihypertensive medications BL

Antihypertensive medications Y1

Y1 ndash Baseline

753

752

-01

737

759

22

023

054

002

1-Year Changes in Markers of Lipid

Control

Markers of Lipid Control ILI DSE P-value

LDL-cholesterol (mgdl) BL

LDL-cholesterol (mgdl) Y1

Y1 ndash Baseline

1122

1070

-52

1124

1067

-57

078

074

049

HDL-cholesterol (mgdl) BL

HDL-cholesterol (mgdl) Y1

Y1 ndash Baseline

435

469

34

436

449

14

080

lt0001

lt0001

Triglycerides (mgdl) BL

Triglycerides (mgdl) Y1

Y1 ndash Baseline

1828

1525

-303

1800

1654

-146

038

lt0001

lt0001

Lipid lowering medications BL

Lipid lowering medications Y1

Y1 ndash Baseline

494

530

37

484

578

94

052

lt0001

lt0001

1-Year Changes in Percent of Participants

Meeting ADA Goals

ADA Goal ILI DSE P-value

Hemoglobin A1c lt 7 BL

Hemoglobin A1c lt 7 Y1

Y1 ndash Baseline

463

727

264

454

508

54

050

lt0001

lt0001

Blood pressure lt 13080 mmHg BL

Blood pressure lt 13080 mmHg Y1

Y1 ndash Baseline

535

686

151

499

570

70

001

lt0001

lt0001

LDL-cholesterol lt 100 mgdl BL

LDL-cholesterol lt 100 mgdl Y1

Y1 ndash Baseline

371

438

67

369

449

80

087

045

034

All three goals BL

All three goals Y1

Y1 ndash Baseline

108

236

128

95

160

65

013

lt0001

lt0001

Mean Changes in Weight Fitness amp BP

Averaged Over Four Years

DSE

Mean

ILI

Mean

P-value

Weight Loss

( initial wt)

-088 -615 lt 00001

Fitness

( METS)

196 1274 lt00001

HbA1c -009 -036 lt 00001

SBP (mm Hg) -297 -533 lt 00001

DBP (mm Hg) -248 -292 0012

Look AHEAD Research Group Arch Int Med 2010

Mean Changes in Lipid Profile

Averaged Over Four Years

DSE

Mean

ILI

Mean

P-value

HDL (mgdl) 197 367 lt00001

TG (mgdl) -1975 -2556 00006

LDL (mgdl) -1284 -1127 0009

LDL (mgdl)

(Adjusting for

medication use)

-922 -875 042

Look AHEAD Research Group Arch Int Med 2010

Percent () Completing Outcome

Measures at Years 1-4

Intervention Group

(ILI)

Year 1 971

Year 2 949

Year 3 940

Year 4 941

Comparison Group

(DSE)

Year 1 957

Year 2 935

Year 3 938

Year 4 931

Look AHEAD Summary

ILI had significantly greater improvements than DSE in all CVD risk factors averaged across 4 years (except LDL-C)

There may be long-term beneficial effects from this 4-year period in which ILI subjects have been exposed to lower CVD risk factors

Longer follow-ups will determine whether these lowered CVD risk factors can be maintained amp whether lifestyle intervention has positive effects on CVD morbidity amp mortality

Mary J

Female

White

56 years old at start of Look AHEAD

study

Past Medical History Type 2 diabetes

overweight diverticulosis arthritis

sleep apnea back pain

Mary J

bullLong term strugglesbull Helping youngest daughter with

personal issues and children

bull Rotator cuff problems

bull Degenerative disks in back

bull Rheumatoid arthritis

bull Diabetes

bull Physically demanding job

bull Financial struggles

Pounds

Years

82007 grandkids enter pre-school

Catherine L

Female

White

47 years old at start of Look AHEAD

study

Past Medical History Type 2 diabetes

overweight high blood pressure

hypothyroidism back pain

Catherine L

Long term struggles

bull Motherrsquos declining health and death

bull Multiple serious injuries

bull Sudden death of sister

bull Death of step-father

bull Declining economy

bull Children living at home

Pounds

Years

Realistic Management Goals

5-10 weight loss

Health energy and fitness

Well-being and self-esteem

Mood and appearance

Functional and recreational

activity

Key Elements

Focus on health and energy

Food and physical activity diaries

Gradual increase in physical activity

Gradual reduction in dietary fat

No feelings of food deprivation

Social support groups

Recommended Strategies for Building

Sustainable Healthy Communities

Overview from USA

Promote the availability of affordable healthy

food and beverages

Support healthy food and beverage choices

Encourage breastfeeding

Encourage physical activity or limit sedentary

activity among children amp youth

Create safe communities that support physical

activity

Encourage communities to organize for change

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Increase the availability of healthier food and

beverage choices in public service venues (eg

schools city amp county buildings etc)

--Insufficient evidence in school-based programs

--Associations suggest availability amp increased

consumption

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve availability of affordable healthier

food amp beverage choices in public service

venues

--Reducing the cost of healthier foods

increases their purchase

--Providing coupons redeemable for

healthier foods increases their purchase

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve geographic availability of

supermarkets in underserved areas

-- Greater access to nearby supermarkets is

associated with healthier eating behaviors

-- Increasing the number of supermarkets in

underserved neighborhoods increased

real estate values increased economic

activity amp employment amp resulted in lower

food prices

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Provide incentives to food retailers to locate in

andor offer healthier food choices in

underserved areas

-- Presence of retail venues that provide healthier

foods is associated with better nutrition

-- Greater availability of supermarkets was

associated with lower adolescent BMI scores

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Improve availability of mechanisms for

purchasing foods from farms

--Evidence supporting a direct link between

purchasing food from farms amp improved diet is

limited

--Two studies of initiatives to encourage

participation in farmersrsquo market showed

increased intention to eat more fruits amp

vegetables but no direct evidence

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Provide incentives for the production

distribution and procurement of foods from local

farms

--No evidence has been published to link local

food production amp health outcomes

--There is a current study exploring the potential

nutritional amp health benefits of eating locally

grown foods

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Restrict availability of less healthy foods amp

beverages in public service venues

--No peer-reviewed studies examined the impact

designed to restrict availability of less healthy

foods in public service venues

--21 states have policies that restrict the sale of

competitive foods in schools beyond USDA

regulations however no studies have evaluated

the impact of the policies

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Institute smaller portion size options in public

service venues

--Evidence is lacking to demonstrate effectiveness

of population-based interventions aimed at

reducing portion sizes in public service venues

--Evidence from clinical studies in laboratories

demonstrates decreasing portion sizes

decreases energy intake

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Limit advertisements of less healthy foods amp

beverages

--Little evidence is available regarding the impact

of restricting advertising on purchasing amp

consumption of less healthy foods

--Cross-sectional time-series studies of tobacco-

control efforts suggest an association between

advertising bans amp decreased tobacco

consumption

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Discourage consumption of sugar-sweetened

beverages

--One longitudinal study of a school-based

intervention among Native-American high school

students showed a substantial reduction in

sugar-sweetened beverages over a 3-year

period

--A RCT of a home-based intervention that

eliminated sugar-sweetened beverages showed

reduction in BMI scores

Recommended Community Strategies Strategies to encourage breastfeeding

Increase support for breastfeeding

--Evidence directly linking environmental

interventions that support breastfeeding with

obesity-related outcomes is lacking

--Epidemiologic studies indicate that breastfeeding

helps prevent pediatric obesity

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Require physical education in schools

--14 studies have demonstrated that school-based

PE was effective in increasing levels of physical

activity and improving physical fitness

--Minimum of 150 minwk in elementary schools

225 minwk in middle schools and high schools

throughout the school year as recommended by

NASPE

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Increase opportunities for extracurricular

physical activity

--Participation in after-school programs increased

studentsrsquo level of physical activity amp improved

obesity-related outcomes (improved CV fitness

reduced body fat)

--2 pilot studies providing extracurricular physical

activity showed increased levels of PA amp

decreased sedentary behavior

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Reduce screen time in public service venues

--A school-based RCT indicated that children who

reduced their television videotape amp video

game use had significant decrease in BMI tricep

skin fold thickness amp waist circumference

compared to controls

--Spending less time watching television is

associated with increased physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Improve access to outdoor recreational

facilities

--Review of 108 studies indicated that access to facilities

and programs for recreation near their homes amp time

spent outdoors correlated positively with increased

physical activity among childrenamp adults

--Perceptions that footpaths are safe for walking was

significantly associated with adults being classified as

physically active at a level sufficient for health benefits

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting

bicycling

--Longitudinal intervention studies have

demonstrated that improving bicycling

infrastructure is associated with increased

frequency of bicycling

--Cross-sectional studies indicated a significant

association between bicycling infrastructure amp

frequency of biking

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting walking

--Reviews of cross-sectional studies of

environmental correlates of physical activity amp

walking generally find a positive association

between infrastructure supportive of walking amp

physical activity

--Identifying amp creating safe routes to school

together with educational components

increased the number of students walking to

school

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Locating schools within easy walking

distance of residential areas

--Community-scale urban design amp land use policies amp

practices including locating schools stores workplaces

amp recreation areas close to residential areas are

effective in facilitating an increase in levels of physical

activity

--Majority of efforts to encourage walking to school involve

improving the routes rather than improving the location

of schools

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Improve access to public transportation

--Insufficient evidence exists to determine

effectiveness of transportation policies in

increasing the level of physical activity or

improving fitness

--1 study indicated that 29 of individuals who

walk to and from public transit achieve at least

30 minutes of daily physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Zone for mixed-use development

--Allows residential commercial institutional amp

other public land uses to be located in close

proximity to one another

--Studies using correlation analyses amp regression

models indicated that mixed land use was

associated with increased walking amp cycling

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance personal safety in areas where

persons are or could be physically active

--Cross-sectional studies have demonstrated a

negative relationship between crime rates andor

perceived safety amp physical activity in

neighborhoods

--Few intervention studies have evaluated the

impact of policies amp practices to improve

personal safety on physical activity

Geospatial Mapping Linking Urban

Environments to Health Risk

Measure association between environmental variables amp health risk factors

Assess relationships between variables at different levels of analysis

Used in conjunction with linear analyses

Our Community Environmental Model

of Obesity

Community Factors

Poverty

Crime

Grocery Quality

Restaurants

Parks

Sidewalks

Fast Food Outlets

Recreational

Facilities

Individual Factors

Dietary Intake

Physical Activity

Genetics

Family History

StressCoping

Eating Disorders

Psychological

Problems

Weight

Status

Chosen Neighborhoods

Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped

We then matched census-block groups within the income groups by population density and percentage of minority representation

One matched block group per income level was randomly selected

Prevalence of Obesity in

Block-Groups

0

5

10

15

20

25

30

35

40

45

50

Ag

e-a

dju

sted

Ob

esit

y P

rev

ale

nce

(

)

High-Income Low-Income

Age-standardized to the 1990 US Census

Density of Environmental Factors in the

Community Contributes to a ldquoToxicrdquo

Obesity Environment

0

2

4

6

8

10

12

14

16

18

Fast-food Convenience Store Bars

Den

sity

10

00

perso

ns

High-Income Low-Income

COMMUNITYrsquoS PERCEPTION OF SAFETY

0

5

10

15

20

25

30

35

40

Daytime Nighttime

Perc

en

t (

) F

eeli

ng

So

mew

hat

Safe

or

Un

safe

Low-Income High-Income

Percent Substandard (or worse) Housing

or Ground Conditions

of Residential Properties

0

10

20

30

Structural Grounds

Perc

en

t (

)

Low-Income High-Income

CONCLUSIONS

These data suggest that the higher

frequency of outlets providing

calorically-dense foods and alcohol may

contribute to greater obesity prevalence

in residents of low-income communities

More research is needed to thoroughly

document environmental determinants

of health and obesity

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

From 1994-1998 HUD randomly assigned

4498 women with children living in public

housing in high-poverty urban census

tracts to one of three groups (1) housing

vouchers redeemable only if they moved

to a low-poverty census tract (2)

unrestricted vouchers or (3) control group

(no vouchers)

Ludwig et al NEJM 201136516

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

10-12 year follow-up showed modest but

potentially important reductions in the

prevalence of extreme obesity amp diabetes in the

group moving from a neighborhood with high

poverty on one of low poverty compared to the

control group

No differences between the group receiving

traditional vouchers amp the control group

ldquoNeighborhoods matterrdquo

Ludwig et al NEJM 201136516

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance traffic safety in areas where

persons are or could be physically active

--Community-scale urban design amp land use policies to

promote physical activity including design components

to improve street lighting infrastructure projects to

increase safety of pedestrian street crossing and use of

traffic calming approaches such as speed humps amp

traffic circles are effective in increasing physical activity

--Both community-scale amp street-scale policies amp practices

are effective in increasing physical activity

Recommended Community Strategies Encourage Communities to Organize for Change

Participate in community coalitions or

partnerships to address obesity

--Little evidence is available to determine the

impact of community coalitions on obesity

prevention

--The presence of anti-smoking community

coalitions has been associated with lower rates

of tobacco consumption

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

$103 million awarded to 61 states and

communities including state amp local government

agencies tribes amp territories amp state amp local non-

profit organizations

To build capacity to implement changes for

community prevention efforts to ensure long-

term success

To implement evidence-based and practice-

based programs to improve health amp wellness

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Priority areas are

Tobacco-free living

Active living and healthy eating

Evidence-based quality clinical and other

preventive health services for prevention

and control of high blood pressure and

high cholesterol

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Applicants proposed specific activities in

line with their chosen priority areas in their

applications

Grantee activities will not be finalized until

plans are negotiated with CDC by early

2012

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Capacity-Building Award

The Confederated Tribes of The Chehalis

Reservation is receiving a $498663 planning

award to build capacity to support healthy

lifestyles among their tribal population of 1500

in Washington State

Work will target tobacco-free living active living

and healthy eating and quality clinical and other

healthy serviceswwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Implementation Award

Austin TX Dept of Health and Human Services

is receiving $1026158 to serve Travis County

(Austin) to expand efforts in tobacco-free living

active living and healthy eating quality clinical

and other preventive services social and

emotional wellness and healthy and safe

physical environmentswwwcdcgov1052011

Building sustainable healthy

communities Bottom line

Obesity is an environmental problem

Despite progress in genetic research public health advances only will occur when we take the environment seriously

Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment

Until we do this we will not make substantial progress in addressing the epidemic of obesity

Poston amp Foreyt Atherosclerosis 1999

Whatrsquos the best approach

Integrate all sectors of society into community

change interventions

Incorporate

Science amp Technology

Education

FamilyCommunity

Healthcare

Arts amp Entertainment

Law amp Politics

Commerce amp Trade

Sectors of Society

Arts amp Entertainm

ent

Commerce amp Trade

Education

FamilyCommunity

Healthcare

Law amp Politics

Science amp Technology

Project FIT rationale design and baseline characteristics of a school- and community-

based intervention to address physical activity and healthy eating among low-income

elementary school children

Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D

Oh HJ Orth J Randall S Mayfield K Holmes D

Source

Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu

Abstract

BACKGROUND

This paper describes Project FIT a collaboration between the public school system local

health systems physicians neighborhood associations businesses faith-based leaders

community agencies and university researchers to develop a multi-faceted approach to

promote physical activity and healthy eating toward the general goal of preventing and

reducing childhood obesity among children in Grand Rapids MI USA

METHODSDESIGN

There are four overall components to Project FIT school community social marketing and

school staff wellness - all that focus on 1) increasing access to safe and affordable physical

activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)

improving the affordability and availability of nutritious food in the neighborhoods surrounding

the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding

nutrition and physical activity among school staff parents and students 4) impacting the

culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging

dialogue among all community partners to leverage existing programs and introduce new

ones

BENEFITS OF MODEST WEIGHT LOSS

ldquoSeveral studies demonstrate that small losseshelliphelp reduce obesity-related co-morbidities and that improvements in these risk factors persist with maintenance of these modest weight lossesrdquo

Institute of Medicine 1995

- Glucose levels - HDL cholesterol levels

- Insulin levels - LDL cholesterol levels

- Glycated hemoglobin - Blood pressure

- Triglyceride levels - Quality of life levels

Stigmatization amp Discrimination

Societal beliefs that weight can be controlled thereby suggestive of character deficits (lack of willpower laziness and emotional problems)

Negative attitudes

ldquoLast safe prejudicerdquo in US society

Rand CSW Macgregor AMC South Med J 1990

DISCRIMINATION

THE PAIN OF OBESITY

Former severely obese patients

100 preferred to be deaf dyslexic

diabetic or have heart disease or bad

acne than to be obese again

Leg amputation was preferred by

915 and blindness by 894

100 preferred to be a normal weight

person rather than a severely obese

multi-millionaire Rand CSW Macgregor AMC Int J Obes 199115577ndash579

Psychosocial Burden of Obesity

Obese individuals often feel misunderstood neglected and rejected

Obese individuals have low employment prospects and are denied educational vocational and advancement opportunities

Significantly poorer quality of life

van Hout GCM van Oudheusden I amp van Heck GL Obes Surg 2004

A Healthy Lifestyle is All About

Balance

Healthy Diet

Healthy Physical Activity

Building Sustainable Healthy

Communities

Healthy Lifestyle

Building Sustainable Healthy

Communities

Healthy Lifestyle

UNFORTUNATELYhellip

Big Texan Steak Ranch

Amarillo Texas

72-oz Steak FREE if eaten within 1 hour

AVERAGE ADULT AMERICAN MAN

Height 5rsquo 8rdquo

Weight 195 lbs

Waist 397 in

BMI 284

CDC 2011

AVERAGE ADULT AMERICAN WOMAN

Height 5rsquo3rdquo

Weight 165 lbs

Waist 370 in

BMI 261

CDC 2011

Miss America

2008

Kirsten Haglund

BMI 1629

Eliana Ramos

Age 18

Height 5rsquo9rdquo

29th OLYMPIAD

BEIJING CHINA

US wrestling team captain Daniel

Cormier (2115 lbs) hospitalized for

kidney failure as result of

dehydration related to cutting weight

(did not compete)

US boxer Gary Russell was found

unconscious 4 days before his

Olympic bout due to cutting weight

(did not compete)

29th OLYMPIAD

BEIJING CHINA

Michael Phelps

8 Gold Medals SwimmingAge 23

Height 6rsquo4rdquo

Weight 195 lbs

BMI 2374

Daily Food Intake 10375 KCAL

(15 PRO 58 CHO 27 FAT)

Exercise 30 hrswk

2005 USDA FOOD PYRAMID

ldquoThe food pyramid

is too complicated

and has too many

messagesrdquo

Robert Post PhD USDA Deputy

Director 2011

2005 USDA FOOD PYRAMID

ldquoItrsquos going to be hard not to do

better than the current pyramid

which basically conveys no

useful informationrdquo

Walter C Willett MD

Chairman Department of Nutrition

Harvard School of Public Health

2011 USDA MY PLATE

ldquoWe are all

bombarded with so

many dietary

messages that it is

hard to find time to

sort through all this

informationrdquo

Michelle Obama 2011

Dietary Guidelines for Americans

2010 Two Primary Concepts

Maintain calorie balance over time to

achieve and maintain a healthy weight

Focus on consuming nutrient-dense foods

and beverages

Dietary Guidelines for Americans 2010

Efficacy-based comparative dietary guidelines

Carb Fat Pro

Mediterranean Diet 45-55 25-35 20

IOM Dietary Ref Intakes 45-65 25-35 15

NCEP-ATPIII 50-60 25-35 15

Am Dietetic Assoc 45-65 20-35 15

PARADOX OF INCREASING OBESITY

PREVALENCE

bull Focus on healthy eating and physical

activity

bull Awareness of dangers of obesity buthellip

bull Obesity prevalence continues to rise

bull Work amp commuting demands

bull Little time to exercise

bull Little time to prepare food

bull Availability of high-fatcalorie foods

Rationale for community-based interventions

bull Increases in obesity prevalence due to genes

bull Increased calories (eg 200 Kcalday

over 10 years)

bull Increased portion sizes (eg 22 oz

steaks and 44 oz sodas)

bull Western diets in developing nations

increase risk of obesity

READINESS TO CHANGE

ldquoHabit is habit and not to be

flung out of the window but

coaxed downstairs a step at a

timerdquo

Mark Twain

Long-Term Weight Maintenance

National Weight Control Registry (N=10000)

Survey of 3000 members who have been in the

Registry for at least 10 years

Starting weight = 224 lbs Average weight loss=69

lbs

At 5 years participants had maintained an average

weight loss=52 lbs

At 10 years participants had maintained an average

weight loss=51 lbs

Thomas Bond Phelan et al TOS 2011

Long-Term Weight Maintenance

Weight Maintainers report that they usually

Track their food intake

Count calories or fat grams

Follow a low-calorie low fat diet (1800 caloriesday

less than 30 of calories from fat

Eat breakfast regularly

Limit the amount they eat out (about 3 timesweek

eat fast food less than onceweek)

Thomas Bond Phelan et al TOS 2011

Long-Term Weight Maintenance

Weight Maintainers report that they usually

Eat similar food regularly

Donrsquot splurge much on holidays amp special occasions

Walk about one hourday

Watch less than 10 hours of TV a week

Weigh themselves at least once a week

Thomas Bond Phelan et al TOS 2011

LONG-TERM WEIGHT MAINTENANCE

Continued consumption of a low-

calorie diet with moderate fat intake

Limited fast food

High levels of physical activity

Phalen et al Obesity 2006 14 710-716

LONG-TERM WEIGHT MAINTENANCE

Daily weighing improved

maintenance of weight loss

particularly when delivered

face to face

Wing et al NEJM 2006 3551563-1571

Most Promising Strategies For

Preventing Weight Regain

Providing multi-component

programs with ongoing

professional contacts

Physical activityexercise

Portion controlmeal replacements

Extending treatment through

weekly or bi-weekly sessions

Pharmacotherapy

Perri Foreyt amp Anton Preventing Weight Regain After Weight Loss 2008

Most Promising Strategies For

Preventing Weight Regain

Extended treatments have shown

promise in promoting adherence to

the behaviors required for the long-

term maintenance of weight loss

Continuous care approach focused

on reasonable long-term objectives

appears appropriate for most

patients

Perri Foreyt amp Anton Preventing Weight Regain After Weight

Loss 2008

An Example of a successful long-term

intervention

The Look AHEAD Study

Does Weight Loss Reduce

Cardiovascular Disease and Death in

Overweight Individuals with Diabetes

bull Action for HEAlth in Diabetes

bull Objective to examine in overweight

persons with Type 2 Diabetes the long-

term effects of an intensive lifestyle

intervention program compared to

diabetes education and support

bull 16 Centers

bull 5145 overweight volunteers with

diabetes

Look AHEAD

Look AHEAD

Primary End Point Composite

bull Cardiovascular death (including fatal

myocardial infarction and stroke)

bull Non-fatal myocardial infarction

bull Non-fatal stroke

Winston-Salem

Baltimore

Philadelphia

New York

Providence

Boston

Clinical Site Coordinating Center

Clinical Sites

Seattle

Los Angeles

San AntonioHouston

Baton Rouge

Minneapolis

Memphis

Birmingham

Pittsburgh

Denver

Phoenix

Look AHEADParticipants

101100Baseline weight (kg)

589586Age (years)

9496Attended 1 year exam

360359Baseline BMI

1514Insulin Users

3737Minority

6059Women

(N=2574)(N=2630)

DSELifestyle

p lt 0004

Look AHEAD

Study Interventions

bull Diabetes support and education - DSE (control group)

bull Lifestyle intervention ndash ILI (treatment group)

Look AHEAD

Lifestyle Intervention

Goals

bull 7 weight loss for the group (10

for individual)

bull 175 minutes of moderate intensity

activity

Look AHEAD

Lifestyle Intervention

bull Diet

ndash ADA NCEP (lt 30 fat lt 10 sat fat

gt15 protein)

ndash 1200-1500 (if weight lt250lbs)

ndash 1500-1800 (if weight gt250lbs)

ndash During first 4 weeks to 4 months portion

control (liquid meal replacements or

structured meal plan)

Look AHEAD

Lifestyle Intervention

bull Physical Activity

ndash unsupervised

ndash 175 minutes moderate intensityweek

ndash 5 daysweek

ndash walking

Weight Loss at 1-Year

-9

ILI 0

-1

-2

-3

-4

-5

-6

-7

-8

DSE

p lt 00001

W

eig

ht

Chan

ge

86

07

The Look AHEAD Research Group Diabetes Care 2007

Reduction in Initial Weight by Gender

N=872

N=1229N=1197

N=830

-12

-10

-8

-6

-4

-2

0

0 2 4 6 8 10 12

Months

R

ed

uctio

n in

In

itia

l W

eig

ht

Men

Women

Plt0001

The Look AHEAD Research Group Diabetes Care 2007

Fitness Change () at 1-Year

0

5

10

15

20

25

Mean

Fitness C

hange

Unadjusted

Plt0001Adjusted for 1 Year

Weight Change Plt0001

58

209

108

159

DSE ILI ILIDSE

The Look AHEAD Research Group Diabetes Care 2007

1-Year Changes in Markers of

Diabetes Control

Markers of Diabetes

Control ILI DSE P-value

Hemoglobin A1c () BL

Hemoglobin A1c () Y1

Y1 ndash Baseline

725

661

-064

729

715

-014

026

lt0001

lt0001

Fasting glucose (mgdl) BL

Fasting glucose (mgdl) Y1

Y1 ndash Baseline

1519

1304

-215

1536

1464

-72

021

lt0001

lt0001

Diabetes medications BL

Diabetes medications Y1

Y1 ndash Baseline

865

786

-78

865

887

22

093

lt0001

lt0001

1-Year Changes in Markers of

Blood Pressure ControlMarkers of Blood Pressure

Control ILI DSE P-value

Systolic BP (mmHg) BL

Systolic BP (mmHg) Y1

Y1 ndash Baseline

1282

1214

-68

1294

1266

-28

026

lt0001

lt0001

Diastolic BP (mmHg) BL

Diastolic BP (mmHg) Y1

Y1 ndash Baseline

699

670

-30

704

686

-18

011

lt0001

lt0001

Antihypertensive medications BL

Antihypertensive medications Y1

Y1 ndash Baseline

753

752

-01

737

759

22

023

054

002

1-Year Changes in Markers of Lipid

Control

Markers of Lipid Control ILI DSE P-value

LDL-cholesterol (mgdl) BL

LDL-cholesterol (mgdl) Y1

Y1 ndash Baseline

1122

1070

-52

1124

1067

-57

078

074

049

HDL-cholesterol (mgdl) BL

HDL-cholesterol (mgdl) Y1

Y1 ndash Baseline

435

469

34

436

449

14

080

lt0001

lt0001

Triglycerides (mgdl) BL

Triglycerides (mgdl) Y1

Y1 ndash Baseline

1828

1525

-303

1800

1654

-146

038

lt0001

lt0001

Lipid lowering medications BL

Lipid lowering medications Y1

Y1 ndash Baseline

494

530

37

484

578

94

052

lt0001

lt0001

1-Year Changes in Percent of Participants

Meeting ADA Goals

ADA Goal ILI DSE P-value

Hemoglobin A1c lt 7 BL

Hemoglobin A1c lt 7 Y1

Y1 ndash Baseline

463

727

264

454

508

54

050

lt0001

lt0001

Blood pressure lt 13080 mmHg BL

Blood pressure lt 13080 mmHg Y1

Y1 ndash Baseline

535

686

151

499

570

70

001

lt0001

lt0001

LDL-cholesterol lt 100 mgdl BL

LDL-cholesterol lt 100 mgdl Y1

Y1 ndash Baseline

371

438

67

369

449

80

087

045

034

All three goals BL

All three goals Y1

Y1 ndash Baseline

108

236

128

95

160

65

013

lt0001

lt0001

Mean Changes in Weight Fitness amp BP

Averaged Over Four Years

DSE

Mean

ILI

Mean

P-value

Weight Loss

( initial wt)

-088 -615 lt 00001

Fitness

( METS)

196 1274 lt00001

HbA1c -009 -036 lt 00001

SBP (mm Hg) -297 -533 lt 00001

DBP (mm Hg) -248 -292 0012

Look AHEAD Research Group Arch Int Med 2010

Mean Changes in Lipid Profile

Averaged Over Four Years

DSE

Mean

ILI

Mean

P-value

HDL (mgdl) 197 367 lt00001

TG (mgdl) -1975 -2556 00006

LDL (mgdl) -1284 -1127 0009

LDL (mgdl)

(Adjusting for

medication use)

-922 -875 042

Look AHEAD Research Group Arch Int Med 2010

Percent () Completing Outcome

Measures at Years 1-4

Intervention Group

(ILI)

Year 1 971

Year 2 949

Year 3 940

Year 4 941

Comparison Group

(DSE)

Year 1 957

Year 2 935

Year 3 938

Year 4 931

Look AHEAD Summary

ILI had significantly greater improvements than DSE in all CVD risk factors averaged across 4 years (except LDL-C)

There may be long-term beneficial effects from this 4-year period in which ILI subjects have been exposed to lower CVD risk factors

Longer follow-ups will determine whether these lowered CVD risk factors can be maintained amp whether lifestyle intervention has positive effects on CVD morbidity amp mortality

Mary J

Female

White

56 years old at start of Look AHEAD

study

Past Medical History Type 2 diabetes

overweight diverticulosis arthritis

sleep apnea back pain

Mary J

bullLong term strugglesbull Helping youngest daughter with

personal issues and children

bull Rotator cuff problems

bull Degenerative disks in back

bull Rheumatoid arthritis

bull Diabetes

bull Physically demanding job

bull Financial struggles

Pounds

Years

82007 grandkids enter pre-school

Catherine L

Female

White

47 years old at start of Look AHEAD

study

Past Medical History Type 2 diabetes

overweight high blood pressure

hypothyroidism back pain

Catherine L

Long term struggles

bull Motherrsquos declining health and death

bull Multiple serious injuries

bull Sudden death of sister

bull Death of step-father

bull Declining economy

bull Children living at home

Pounds

Years

Realistic Management Goals

5-10 weight loss

Health energy and fitness

Well-being and self-esteem

Mood and appearance

Functional and recreational

activity

Key Elements

Focus on health and energy

Food and physical activity diaries

Gradual increase in physical activity

Gradual reduction in dietary fat

No feelings of food deprivation

Social support groups

Recommended Strategies for Building

Sustainable Healthy Communities

Overview from USA

Promote the availability of affordable healthy

food and beverages

Support healthy food and beverage choices

Encourage breastfeeding

Encourage physical activity or limit sedentary

activity among children amp youth

Create safe communities that support physical

activity

Encourage communities to organize for change

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Increase the availability of healthier food and

beverage choices in public service venues (eg

schools city amp county buildings etc)

--Insufficient evidence in school-based programs

--Associations suggest availability amp increased

consumption

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve availability of affordable healthier

food amp beverage choices in public service

venues

--Reducing the cost of healthier foods

increases their purchase

--Providing coupons redeemable for

healthier foods increases their purchase

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve geographic availability of

supermarkets in underserved areas

-- Greater access to nearby supermarkets is

associated with healthier eating behaviors

-- Increasing the number of supermarkets in

underserved neighborhoods increased

real estate values increased economic

activity amp employment amp resulted in lower

food prices

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Provide incentives to food retailers to locate in

andor offer healthier food choices in

underserved areas

-- Presence of retail venues that provide healthier

foods is associated with better nutrition

-- Greater availability of supermarkets was

associated with lower adolescent BMI scores

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Improve availability of mechanisms for

purchasing foods from farms

--Evidence supporting a direct link between

purchasing food from farms amp improved diet is

limited

--Two studies of initiatives to encourage

participation in farmersrsquo market showed

increased intention to eat more fruits amp

vegetables but no direct evidence

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Provide incentives for the production

distribution and procurement of foods from local

farms

--No evidence has been published to link local

food production amp health outcomes

--There is a current study exploring the potential

nutritional amp health benefits of eating locally

grown foods

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Restrict availability of less healthy foods amp

beverages in public service venues

--No peer-reviewed studies examined the impact

designed to restrict availability of less healthy

foods in public service venues

--21 states have policies that restrict the sale of

competitive foods in schools beyond USDA

regulations however no studies have evaluated

the impact of the policies

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Institute smaller portion size options in public

service venues

--Evidence is lacking to demonstrate effectiveness

of population-based interventions aimed at

reducing portion sizes in public service venues

--Evidence from clinical studies in laboratories

demonstrates decreasing portion sizes

decreases energy intake

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Limit advertisements of less healthy foods amp

beverages

--Little evidence is available regarding the impact

of restricting advertising on purchasing amp

consumption of less healthy foods

--Cross-sectional time-series studies of tobacco-

control efforts suggest an association between

advertising bans amp decreased tobacco

consumption

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Discourage consumption of sugar-sweetened

beverages

--One longitudinal study of a school-based

intervention among Native-American high school

students showed a substantial reduction in

sugar-sweetened beverages over a 3-year

period

--A RCT of a home-based intervention that

eliminated sugar-sweetened beverages showed

reduction in BMI scores

Recommended Community Strategies Strategies to encourage breastfeeding

Increase support for breastfeeding

--Evidence directly linking environmental

interventions that support breastfeeding with

obesity-related outcomes is lacking

--Epidemiologic studies indicate that breastfeeding

helps prevent pediatric obesity

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Require physical education in schools

--14 studies have demonstrated that school-based

PE was effective in increasing levels of physical

activity and improving physical fitness

--Minimum of 150 minwk in elementary schools

225 minwk in middle schools and high schools

throughout the school year as recommended by

NASPE

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Increase opportunities for extracurricular

physical activity

--Participation in after-school programs increased

studentsrsquo level of physical activity amp improved

obesity-related outcomes (improved CV fitness

reduced body fat)

--2 pilot studies providing extracurricular physical

activity showed increased levels of PA amp

decreased sedentary behavior

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Reduce screen time in public service venues

--A school-based RCT indicated that children who

reduced their television videotape amp video

game use had significant decrease in BMI tricep

skin fold thickness amp waist circumference

compared to controls

--Spending less time watching television is

associated with increased physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Improve access to outdoor recreational

facilities

--Review of 108 studies indicated that access to facilities

and programs for recreation near their homes amp time

spent outdoors correlated positively with increased

physical activity among childrenamp adults

--Perceptions that footpaths are safe for walking was

significantly associated with adults being classified as

physically active at a level sufficient for health benefits

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting

bicycling

--Longitudinal intervention studies have

demonstrated that improving bicycling

infrastructure is associated with increased

frequency of bicycling

--Cross-sectional studies indicated a significant

association between bicycling infrastructure amp

frequency of biking

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting walking

--Reviews of cross-sectional studies of

environmental correlates of physical activity amp

walking generally find a positive association

between infrastructure supportive of walking amp

physical activity

--Identifying amp creating safe routes to school

together with educational components

increased the number of students walking to

school

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Locating schools within easy walking

distance of residential areas

--Community-scale urban design amp land use policies amp

practices including locating schools stores workplaces

amp recreation areas close to residential areas are

effective in facilitating an increase in levels of physical

activity

--Majority of efforts to encourage walking to school involve

improving the routes rather than improving the location

of schools

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Improve access to public transportation

--Insufficient evidence exists to determine

effectiveness of transportation policies in

increasing the level of physical activity or

improving fitness

--1 study indicated that 29 of individuals who

walk to and from public transit achieve at least

30 minutes of daily physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Zone for mixed-use development

--Allows residential commercial institutional amp

other public land uses to be located in close

proximity to one another

--Studies using correlation analyses amp regression

models indicated that mixed land use was

associated with increased walking amp cycling

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance personal safety in areas where

persons are or could be physically active

--Cross-sectional studies have demonstrated a

negative relationship between crime rates andor

perceived safety amp physical activity in

neighborhoods

--Few intervention studies have evaluated the

impact of policies amp practices to improve

personal safety on physical activity

Geospatial Mapping Linking Urban

Environments to Health Risk

Measure association between environmental variables amp health risk factors

Assess relationships between variables at different levels of analysis

Used in conjunction with linear analyses

Our Community Environmental Model

of Obesity

Community Factors

Poverty

Crime

Grocery Quality

Restaurants

Parks

Sidewalks

Fast Food Outlets

Recreational

Facilities

Individual Factors

Dietary Intake

Physical Activity

Genetics

Family History

StressCoping

Eating Disorders

Psychological

Problems

Weight

Status

Chosen Neighborhoods

Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped

We then matched census-block groups within the income groups by population density and percentage of minority representation

One matched block group per income level was randomly selected

Prevalence of Obesity in

Block-Groups

0

5

10

15

20

25

30

35

40

45

50

Ag

e-a

dju

sted

Ob

esit

y P

rev

ale

nce

(

)

High-Income Low-Income

Age-standardized to the 1990 US Census

Density of Environmental Factors in the

Community Contributes to a ldquoToxicrdquo

Obesity Environment

0

2

4

6

8

10

12

14

16

18

Fast-food Convenience Store Bars

Den

sity

10

00

perso

ns

High-Income Low-Income

COMMUNITYrsquoS PERCEPTION OF SAFETY

0

5

10

15

20

25

30

35

40

Daytime Nighttime

Perc

en

t (

) F

eeli

ng

So

mew

hat

Safe

or

Un

safe

Low-Income High-Income

Percent Substandard (or worse) Housing

or Ground Conditions

of Residential Properties

0

10

20

30

Structural Grounds

Perc

en

t (

)

Low-Income High-Income

CONCLUSIONS

These data suggest that the higher

frequency of outlets providing

calorically-dense foods and alcohol may

contribute to greater obesity prevalence

in residents of low-income communities

More research is needed to thoroughly

document environmental determinants

of health and obesity

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

From 1994-1998 HUD randomly assigned

4498 women with children living in public

housing in high-poverty urban census

tracts to one of three groups (1) housing

vouchers redeemable only if they moved

to a low-poverty census tract (2)

unrestricted vouchers or (3) control group

(no vouchers)

Ludwig et al NEJM 201136516

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

10-12 year follow-up showed modest but

potentially important reductions in the

prevalence of extreme obesity amp diabetes in the

group moving from a neighborhood with high

poverty on one of low poverty compared to the

control group

No differences between the group receiving

traditional vouchers amp the control group

ldquoNeighborhoods matterrdquo

Ludwig et al NEJM 201136516

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance traffic safety in areas where

persons are or could be physically active

--Community-scale urban design amp land use policies to

promote physical activity including design components

to improve street lighting infrastructure projects to

increase safety of pedestrian street crossing and use of

traffic calming approaches such as speed humps amp

traffic circles are effective in increasing physical activity

--Both community-scale amp street-scale policies amp practices

are effective in increasing physical activity

Recommended Community Strategies Encourage Communities to Organize for Change

Participate in community coalitions or

partnerships to address obesity

--Little evidence is available to determine the

impact of community coalitions on obesity

prevention

--The presence of anti-smoking community

coalitions has been associated with lower rates

of tobacco consumption

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

$103 million awarded to 61 states and

communities including state amp local government

agencies tribes amp territories amp state amp local non-

profit organizations

To build capacity to implement changes for

community prevention efforts to ensure long-

term success

To implement evidence-based and practice-

based programs to improve health amp wellness

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Priority areas are

Tobacco-free living

Active living and healthy eating

Evidence-based quality clinical and other

preventive health services for prevention

and control of high blood pressure and

high cholesterol

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Applicants proposed specific activities in

line with their chosen priority areas in their

applications

Grantee activities will not be finalized until

plans are negotiated with CDC by early

2012

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Capacity-Building Award

The Confederated Tribes of The Chehalis

Reservation is receiving a $498663 planning

award to build capacity to support healthy

lifestyles among their tribal population of 1500

in Washington State

Work will target tobacco-free living active living

and healthy eating and quality clinical and other

healthy serviceswwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Implementation Award

Austin TX Dept of Health and Human Services

is receiving $1026158 to serve Travis County

(Austin) to expand efforts in tobacco-free living

active living and healthy eating quality clinical

and other preventive services social and

emotional wellness and healthy and safe

physical environmentswwwcdcgov1052011

Building sustainable healthy

communities Bottom line

Obesity is an environmental problem

Despite progress in genetic research public health advances only will occur when we take the environment seriously

Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment

Until we do this we will not make substantial progress in addressing the epidemic of obesity

Poston amp Foreyt Atherosclerosis 1999

Whatrsquos the best approach

Integrate all sectors of society into community

change interventions

Incorporate

Science amp Technology

Education

FamilyCommunity

Healthcare

Arts amp Entertainment

Law amp Politics

Commerce amp Trade

Sectors of Society

Arts amp Entertainm

ent

Commerce amp Trade

Education

FamilyCommunity

Healthcare

Law amp Politics

Science amp Technology

Project FIT rationale design and baseline characteristics of a school- and community-

based intervention to address physical activity and healthy eating among low-income

elementary school children

Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D

Oh HJ Orth J Randall S Mayfield K Holmes D

Source

Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu

Abstract

BACKGROUND

This paper describes Project FIT a collaboration between the public school system local

health systems physicians neighborhood associations businesses faith-based leaders

community agencies and university researchers to develop a multi-faceted approach to

promote physical activity and healthy eating toward the general goal of preventing and

reducing childhood obesity among children in Grand Rapids MI USA

METHODSDESIGN

There are four overall components to Project FIT school community social marketing and

school staff wellness - all that focus on 1) increasing access to safe and affordable physical

activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)

improving the affordability and availability of nutritious food in the neighborhoods surrounding

the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding

nutrition and physical activity among school staff parents and students 4) impacting the

culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging

dialogue among all community partners to leverage existing programs and introduce new

ones

Stigmatization amp Discrimination

Societal beliefs that weight can be controlled thereby suggestive of character deficits (lack of willpower laziness and emotional problems)

Negative attitudes

ldquoLast safe prejudicerdquo in US society

Rand CSW Macgregor AMC South Med J 1990

DISCRIMINATION

THE PAIN OF OBESITY

Former severely obese patients

100 preferred to be deaf dyslexic

diabetic or have heart disease or bad

acne than to be obese again

Leg amputation was preferred by

915 and blindness by 894

100 preferred to be a normal weight

person rather than a severely obese

multi-millionaire Rand CSW Macgregor AMC Int J Obes 199115577ndash579

Psychosocial Burden of Obesity

Obese individuals often feel misunderstood neglected and rejected

Obese individuals have low employment prospects and are denied educational vocational and advancement opportunities

Significantly poorer quality of life

van Hout GCM van Oudheusden I amp van Heck GL Obes Surg 2004

A Healthy Lifestyle is All About

Balance

Healthy Diet

Healthy Physical Activity

Building Sustainable Healthy

Communities

Healthy Lifestyle

Building Sustainable Healthy

Communities

Healthy Lifestyle

UNFORTUNATELYhellip

Big Texan Steak Ranch

Amarillo Texas

72-oz Steak FREE if eaten within 1 hour

AVERAGE ADULT AMERICAN MAN

Height 5rsquo 8rdquo

Weight 195 lbs

Waist 397 in

BMI 284

CDC 2011

AVERAGE ADULT AMERICAN WOMAN

Height 5rsquo3rdquo

Weight 165 lbs

Waist 370 in

BMI 261

CDC 2011

Miss America

2008

Kirsten Haglund

BMI 1629

Eliana Ramos

Age 18

Height 5rsquo9rdquo

29th OLYMPIAD

BEIJING CHINA

US wrestling team captain Daniel

Cormier (2115 lbs) hospitalized for

kidney failure as result of

dehydration related to cutting weight

(did not compete)

US boxer Gary Russell was found

unconscious 4 days before his

Olympic bout due to cutting weight

(did not compete)

29th OLYMPIAD

BEIJING CHINA

Michael Phelps

8 Gold Medals SwimmingAge 23

Height 6rsquo4rdquo

Weight 195 lbs

BMI 2374

Daily Food Intake 10375 KCAL

(15 PRO 58 CHO 27 FAT)

Exercise 30 hrswk

2005 USDA FOOD PYRAMID

ldquoThe food pyramid

is too complicated

and has too many

messagesrdquo

Robert Post PhD USDA Deputy

Director 2011

2005 USDA FOOD PYRAMID

ldquoItrsquos going to be hard not to do

better than the current pyramid

which basically conveys no

useful informationrdquo

Walter C Willett MD

Chairman Department of Nutrition

Harvard School of Public Health

2011 USDA MY PLATE

ldquoWe are all

bombarded with so

many dietary

messages that it is

hard to find time to

sort through all this

informationrdquo

Michelle Obama 2011

Dietary Guidelines for Americans

2010 Two Primary Concepts

Maintain calorie balance over time to

achieve and maintain a healthy weight

Focus on consuming nutrient-dense foods

and beverages

Dietary Guidelines for Americans 2010

Efficacy-based comparative dietary guidelines

Carb Fat Pro

Mediterranean Diet 45-55 25-35 20

IOM Dietary Ref Intakes 45-65 25-35 15

NCEP-ATPIII 50-60 25-35 15

Am Dietetic Assoc 45-65 20-35 15

PARADOX OF INCREASING OBESITY

PREVALENCE

bull Focus on healthy eating and physical

activity

bull Awareness of dangers of obesity buthellip

bull Obesity prevalence continues to rise

bull Work amp commuting demands

bull Little time to exercise

bull Little time to prepare food

bull Availability of high-fatcalorie foods

Rationale for community-based interventions

bull Increases in obesity prevalence due to genes

bull Increased calories (eg 200 Kcalday

over 10 years)

bull Increased portion sizes (eg 22 oz

steaks and 44 oz sodas)

bull Western diets in developing nations

increase risk of obesity

READINESS TO CHANGE

ldquoHabit is habit and not to be

flung out of the window but

coaxed downstairs a step at a

timerdquo

Mark Twain

Long-Term Weight Maintenance

National Weight Control Registry (N=10000)

Survey of 3000 members who have been in the

Registry for at least 10 years

Starting weight = 224 lbs Average weight loss=69

lbs

At 5 years participants had maintained an average

weight loss=52 lbs

At 10 years participants had maintained an average

weight loss=51 lbs

Thomas Bond Phelan et al TOS 2011

Long-Term Weight Maintenance

Weight Maintainers report that they usually

Track their food intake

Count calories or fat grams

Follow a low-calorie low fat diet (1800 caloriesday

less than 30 of calories from fat

Eat breakfast regularly

Limit the amount they eat out (about 3 timesweek

eat fast food less than onceweek)

Thomas Bond Phelan et al TOS 2011

Long-Term Weight Maintenance

Weight Maintainers report that they usually

Eat similar food regularly

Donrsquot splurge much on holidays amp special occasions

Walk about one hourday

Watch less than 10 hours of TV a week

Weigh themselves at least once a week

Thomas Bond Phelan et al TOS 2011

LONG-TERM WEIGHT MAINTENANCE

Continued consumption of a low-

calorie diet with moderate fat intake

Limited fast food

High levels of physical activity

Phalen et al Obesity 2006 14 710-716

LONG-TERM WEIGHT MAINTENANCE

Daily weighing improved

maintenance of weight loss

particularly when delivered

face to face

Wing et al NEJM 2006 3551563-1571

Most Promising Strategies For

Preventing Weight Regain

Providing multi-component

programs with ongoing

professional contacts

Physical activityexercise

Portion controlmeal replacements

Extending treatment through

weekly or bi-weekly sessions

Pharmacotherapy

Perri Foreyt amp Anton Preventing Weight Regain After Weight Loss 2008

Most Promising Strategies For

Preventing Weight Regain

Extended treatments have shown

promise in promoting adherence to

the behaviors required for the long-

term maintenance of weight loss

Continuous care approach focused

on reasonable long-term objectives

appears appropriate for most

patients

Perri Foreyt amp Anton Preventing Weight Regain After Weight

Loss 2008

An Example of a successful long-term

intervention

The Look AHEAD Study

Does Weight Loss Reduce

Cardiovascular Disease and Death in

Overweight Individuals with Diabetes

bull Action for HEAlth in Diabetes

bull Objective to examine in overweight

persons with Type 2 Diabetes the long-

term effects of an intensive lifestyle

intervention program compared to

diabetes education and support

bull 16 Centers

bull 5145 overweight volunteers with

diabetes

Look AHEAD

Look AHEAD

Primary End Point Composite

bull Cardiovascular death (including fatal

myocardial infarction and stroke)

bull Non-fatal myocardial infarction

bull Non-fatal stroke

Winston-Salem

Baltimore

Philadelphia

New York

Providence

Boston

Clinical Site Coordinating Center

Clinical Sites

Seattle

Los Angeles

San AntonioHouston

Baton Rouge

Minneapolis

Memphis

Birmingham

Pittsburgh

Denver

Phoenix

Look AHEADParticipants

101100Baseline weight (kg)

589586Age (years)

9496Attended 1 year exam

360359Baseline BMI

1514Insulin Users

3737Minority

6059Women

(N=2574)(N=2630)

DSELifestyle

p lt 0004

Look AHEAD

Study Interventions

bull Diabetes support and education - DSE (control group)

bull Lifestyle intervention ndash ILI (treatment group)

Look AHEAD

Lifestyle Intervention

Goals

bull 7 weight loss for the group (10

for individual)

bull 175 minutes of moderate intensity

activity

Look AHEAD

Lifestyle Intervention

bull Diet

ndash ADA NCEP (lt 30 fat lt 10 sat fat

gt15 protein)

ndash 1200-1500 (if weight lt250lbs)

ndash 1500-1800 (if weight gt250lbs)

ndash During first 4 weeks to 4 months portion

control (liquid meal replacements or

structured meal plan)

Look AHEAD

Lifestyle Intervention

bull Physical Activity

ndash unsupervised

ndash 175 minutes moderate intensityweek

ndash 5 daysweek

ndash walking

Weight Loss at 1-Year

-9

ILI 0

-1

-2

-3

-4

-5

-6

-7

-8

DSE

p lt 00001

W

eig

ht

Chan

ge

86

07

The Look AHEAD Research Group Diabetes Care 2007

Reduction in Initial Weight by Gender

N=872

N=1229N=1197

N=830

-12

-10

-8

-6

-4

-2

0

0 2 4 6 8 10 12

Months

R

ed

uctio

n in

In

itia

l W

eig

ht

Men

Women

Plt0001

The Look AHEAD Research Group Diabetes Care 2007

Fitness Change () at 1-Year

0

5

10

15

20

25

Mean

Fitness C

hange

Unadjusted

Plt0001Adjusted for 1 Year

Weight Change Plt0001

58

209

108

159

DSE ILI ILIDSE

The Look AHEAD Research Group Diabetes Care 2007

1-Year Changes in Markers of

Diabetes Control

Markers of Diabetes

Control ILI DSE P-value

Hemoglobin A1c () BL

Hemoglobin A1c () Y1

Y1 ndash Baseline

725

661

-064

729

715

-014

026

lt0001

lt0001

Fasting glucose (mgdl) BL

Fasting glucose (mgdl) Y1

Y1 ndash Baseline

1519

1304

-215

1536

1464

-72

021

lt0001

lt0001

Diabetes medications BL

Diabetes medications Y1

Y1 ndash Baseline

865

786

-78

865

887

22

093

lt0001

lt0001

1-Year Changes in Markers of

Blood Pressure ControlMarkers of Blood Pressure

Control ILI DSE P-value

Systolic BP (mmHg) BL

Systolic BP (mmHg) Y1

Y1 ndash Baseline

1282

1214

-68

1294

1266

-28

026

lt0001

lt0001

Diastolic BP (mmHg) BL

Diastolic BP (mmHg) Y1

Y1 ndash Baseline

699

670

-30

704

686

-18

011

lt0001

lt0001

Antihypertensive medications BL

Antihypertensive medications Y1

Y1 ndash Baseline

753

752

-01

737

759

22

023

054

002

1-Year Changes in Markers of Lipid

Control

Markers of Lipid Control ILI DSE P-value

LDL-cholesterol (mgdl) BL

LDL-cholesterol (mgdl) Y1

Y1 ndash Baseline

1122

1070

-52

1124

1067

-57

078

074

049

HDL-cholesterol (mgdl) BL

HDL-cholesterol (mgdl) Y1

Y1 ndash Baseline

435

469

34

436

449

14

080

lt0001

lt0001

Triglycerides (mgdl) BL

Triglycerides (mgdl) Y1

Y1 ndash Baseline

1828

1525

-303

1800

1654

-146

038

lt0001

lt0001

Lipid lowering medications BL

Lipid lowering medications Y1

Y1 ndash Baseline

494

530

37

484

578

94

052

lt0001

lt0001

1-Year Changes in Percent of Participants

Meeting ADA Goals

ADA Goal ILI DSE P-value

Hemoglobin A1c lt 7 BL

Hemoglobin A1c lt 7 Y1

Y1 ndash Baseline

463

727

264

454

508

54

050

lt0001

lt0001

Blood pressure lt 13080 mmHg BL

Blood pressure lt 13080 mmHg Y1

Y1 ndash Baseline

535

686

151

499

570

70

001

lt0001

lt0001

LDL-cholesterol lt 100 mgdl BL

LDL-cholesterol lt 100 mgdl Y1

Y1 ndash Baseline

371

438

67

369

449

80

087

045

034

All three goals BL

All three goals Y1

Y1 ndash Baseline

108

236

128

95

160

65

013

lt0001

lt0001

Mean Changes in Weight Fitness amp BP

Averaged Over Four Years

DSE

Mean

ILI

Mean

P-value

Weight Loss

( initial wt)

-088 -615 lt 00001

Fitness

( METS)

196 1274 lt00001

HbA1c -009 -036 lt 00001

SBP (mm Hg) -297 -533 lt 00001

DBP (mm Hg) -248 -292 0012

Look AHEAD Research Group Arch Int Med 2010

Mean Changes in Lipid Profile

Averaged Over Four Years

DSE

Mean

ILI

Mean

P-value

HDL (mgdl) 197 367 lt00001

TG (mgdl) -1975 -2556 00006

LDL (mgdl) -1284 -1127 0009

LDL (mgdl)

(Adjusting for

medication use)

-922 -875 042

Look AHEAD Research Group Arch Int Med 2010

Percent () Completing Outcome

Measures at Years 1-4

Intervention Group

(ILI)

Year 1 971

Year 2 949

Year 3 940

Year 4 941

Comparison Group

(DSE)

Year 1 957

Year 2 935

Year 3 938

Year 4 931

Look AHEAD Summary

ILI had significantly greater improvements than DSE in all CVD risk factors averaged across 4 years (except LDL-C)

There may be long-term beneficial effects from this 4-year period in which ILI subjects have been exposed to lower CVD risk factors

Longer follow-ups will determine whether these lowered CVD risk factors can be maintained amp whether lifestyle intervention has positive effects on CVD morbidity amp mortality

Mary J

Female

White

56 years old at start of Look AHEAD

study

Past Medical History Type 2 diabetes

overweight diverticulosis arthritis

sleep apnea back pain

Mary J

bullLong term strugglesbull Helping youngest daughter with

personal issues and children

bull Rotator cuff problems

bull Degenerative disks in back

bull Rheumatoid arthritis

bull Diabetes

bull Physically demanding job

bull Financial struggles

Pounds

Years

82007 grandkids enter pre-school

Catherine L

Female

White

47 years old at start of Look AHEAD

study

Past Medical History Type 2 diabetes

overweight high blood pressure

hypothyroidism back pain

Catherine L

Long term struggles

bull Motherrsquos declining health and death

bull Multiple serious injuries

bull Sudden death of sister

bull Death of step-father

bull Declining economy

bull Children living at home

Pounds

Years

Realistic Management Goals

5-10 weight loss

Health energy and fitness

Well-being and self-esteem

Mood and appearance

Functional and recreational

activity

Key Elements

Focus on health and energy

Food and physical activity diaries

Gradual increase in physical activity

Gradual reduction in dietary fat

No feelings of food deprivation

Social support groups

Recommended Strategies for Building

Sustainable Healthy Communities

Overview from USA

Promote the availability of affordable healthy

food and beverages

Support healthy food and beverage choices

Encourage breastfeeding

Encourage physical activity or limit sedentary

activity among children amp youth

Create safe communities that support physical

activity

Encourage communities to organize for change

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Increase the availability of healthier food and

beverage choices in public service venues (eg

schools city amp county buildings etc)

--Insufficient evidence in school-based programs

--Associations suggest availability amp increased

consumption

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve availability of affordable healthier

food amp beverage choices in public service

venues

--Reducing the cost of healthier foods

increases their purchase

--Providing coupons redeemable for

healthier foods increases their purchase

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve geographic availability of

supermarkets in underserved areas

-- Greater access to nearby supermarkets is

associated with healthier eating behaviors

-- Increasing the number of supermarkets in

underserved neighborhoods increased

real estate values increased economic

activity amp employment amp resulted in lower

food prices

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Provide incentives to food retailers to locate in

andor offer healthier food choices in

underserved areas

-- Presence of retail venues that provide healthier

foods is associated with better nutrition

-- Greater availability of supermarkets was

associated with lower adolescent BMI scores

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Improve availability of mechanisms for

purchasing foods from farms

--Evidence supporting a direct link between

purchasing food from farms amp improved diet is

limited

--Two studies of initiatives to encourage

participation in farmersrsquo market showed

increased intention to eat more fruits amp

vegetables but no direct evidence

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Provide incentives for the production

distribution and procurement of foods from local

farms

--No evidence has been published to link local

food production amp health outcomes

--There is a current study exploring the potential

nutritional amp health benefits of eating locally

grown foods

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Restrict availability of less healthy foods amp

beverages in public service venues

--No peer-reviewed studies examined the impact

designed to restrict availability of less healthy

foods in public service venues

--21 states have policies that restrict the sale of

competitive foods in schools beyond USDA

regulations however no studies have evaluated

the impact of the policies

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Institute smaller portion size options in public

service venues

--Evidence is lacking to demonstrate effectiveness

of population-based interventions aimed at

reducing portion sizes in public service venues

--Evidence from clinical studies in laboratories

demonstrates decreasing portion sizes

decreases energy intake

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Limit advertisements of less healthy foods amp

beverages

--Little evidence is available regarding the impact

of restricting advertising on purchasing amp

consumption of less healthy foods

--Cross-sectional time-series studies of tobacco-

control efforts suggest an association between

advertising bans amp decreased tobacco

consumption

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Discourage consumption of sugar-sweetened

beverages

--One longitudinal study of a school-based

intervention among Native-American high school

students showed a substantial reduction in

sugar-sweetened beverages over a 3-year

period

--A RCT of a home-based intervention that

eliminated sugar-sweetened beverages showed

reduction in BMI scores

Recommended Community Strategies Strategies to encourage breastfeeding

Increase support for breastfeeding

--Evidence directly linking environmental

interventions that support breastfeeding with

obesity-related outcomes is lacking

--Epidemiologic studies indicate that breastfeeding

helps prevent pediatric obesity

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Require physical education in schools

--14 studies have demonstrated that school-based

PE was effective in increasing levels of physical

activity and improving physical fitness

--Minimum of 150 minwk in elementary schools

225 minwk in middle schools and high schools

throughout the school year as recommended by

NASPE

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Increase opportunities for extracurricular

physical activity

--Participation in after-school programs increased

studentsrsquo level of physical activity amp improved

obesity-related outcomes (improved CV fitness

reduced body fat)

--2 pilot studies providing extracurricular physical

activity showed increased levels of PA amp

decreased sedentary behavior

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Reduce screen time in public service venues

--A school-based RCT indicated that children who

reduced their television videotape amp video

game use had significant decrease in BMI tricep

skin fold thickness amp waist circumference

compared to controls

--Spending less time watching television is

associated with increased physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Improve access to outdoor recreational

facilities

--Review of 108 studies indicated that access to facilities

and programs for recreation near their homes amp time

spent outdoors correlated positively with increased

physical activity among childrenamp adults

--Perceptions that footpaths are safe for walking was

significantly associated with adults being classified as

physically active at a level sufficient for health benefits

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting

bicycling

--Longitudinal intervention studies have

demonstrated that improving bicycling

infrastructure is associated with increased

frequency of bicycling

--Cross-sectional studies indicated a significant

association between bicycling infrastructure amp

frequency of biking

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting walking

--Reviews of cross-sectional studies of

environmental correlates of physical activity amp

walking generally find a positive association

between infrastructure supportive of walking amp

physical activity

--Identifying amp creating safe routes to school

together with educational components

increased the number of students walking to

school

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Locating schools within easy walking

distance of residential areas

--Community-scale urban design amp land use policies amp

practices including locating schools stores workplaces

amp recreation areas close to residential areas are

effective in facilitating an increase in levels of physical

activity

--Majority of efforts to encourage walking to school involve

improving the routes rather than improving the location

of schools

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Improve access to public transportation

--Insufficient evidence exists to determine

effectiveness of transportation policies in

increasing the level of physical activity or

improving fitness

--1 study indicated that 29 of individuals who

walk to and from public transit achieve at least

30 minutes of daily physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Zone for mixed-use development

--Allows residential commercial institutional amp

other public land uses to be located in close

proximity to one another

--Studies using correlation analyses amp regression

models indicated that mixed land use was

associated with increased walking amp cycling

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance personal safety in areas where

persons are or could be physically active

--Cross-sectional studies have demonstrated a

negative relationship between crime rates andor

perceived safety amp physical activity in

neighborhoods

--Few intervention studies have evaluated the

impact of policies amp practices to improve

personal safety on physical activity

Geospatial Mapping Linking Urban

Environments to Health Risk

Measure association between environmental variables amp health risk factors

Assess relationships between variables at different levels of analysis

Used in conjunction with linear analyses

Our Community Environmental Model

of Obesity

Community Factors

Poverty

Crime

Grocery Quality

Restaurants

Parks

Sidewalks

Fast Food Outlets

Recreational

Facilities

Individual Factors

Dietary Intake

Physical Activity

Genetics

Family History

StressCoping

Eating Disorders

Psychological

Problems

Weight

Status

Chosen Neighborhoods

Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped

We then matched census-block groups within the income groups by population density and percentage of minority representation

One matched block group per income level was randomly selected

Prevalence of Obesity in

Block-Groups

0

5

10

15

20

25

30

35

40

45

50

Ag

e-a

dju

sted

Ob

esit

y P

rev

ale

nce

(

)

High-Income Low-Income

Age-standardized to the 1990 US Census

Density of Environmental Factors in the

Community Contributes to a ldquoToxicrdquo

Obesity Environment

0

2

4

6

8

10

12

14

16

18

Fast-food Convenience Store Bars

Den

sity

10

00

perso

ns

High-Income Low-Income

COMMUNITYrsquoS PERCEPTION OF SAFETY

0

5

10

15

20

25

30

35

40

Daytime Nighttime

Perc

en

t (

) F

eeli

ng

So

mew

hat

Safe

or

Un

safe

Low-Income High-Income

Percent Substandard (or worse) Housing

or Ground Conditions

of Residential Properties

0

10

20

30

Structural Grounds

Perc

en

t (

)

Low-Income High-Income

CONCLUSIONS

These data suggest that the higher

frequency of outlets providing

calorically-dense foods and alcohol may

contribute to greater obesity prevalence

in residents of low-income communities

More research is needed to thoroughly

document environmental determinants

of health and obesity

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

From 1994-1998 HUD randomly assigned

4498 women with children living in public

housing in high-poverty urban census

tracts to one of three groups (1) housing

vouchers redeemable only if they moved

to a low-poverty census tract (2)

unrestricted vouchers or (3) control group

(no vouchers)

Ludwig et al NEJM 201136516

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

10-12 year follow-up showed modest but

potentially important reductions in the

prevalence of extreme obesity amp diabetes in the

group moving from a neighborhood with high

poverty on one of low poverty compared to the

control group

No differences between the group receiving

traditional vouchers amp the control group

ldquoNeighborhoods matterrdquo

Ludwig et al NEJM 201136516

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance traffic safety in areas where

persons are or could be physically active

--Community-scale urban design amp land use policies to

promote physical activity including design components

to improve street lighting infrastructure projects to

increase safety of pedestrian street crossing and use of

traffic calming approaches such as speed humps amp

traffic circles are effective in increasing physical activity

--Both community-scale amp street-scale policies amp practices

are effective in increasing physical activity

Recommended Community Strategies Encourage Communities to Organize for Change

Participate in community coalitions or

partnerships to address obesity

--Little evidence is available to determine the

impact of community coalitions on obesity

prevention

--The presence of anti-smoking community

coalitions has been associated with lower rates

of tobacco consumption

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

$103 million awarded to 61 states and

communities including state amp local government

agencies tribes amp territories amp state amp local non-

profit organizations

To build capacity to implement changes for

community prevention efforts to ensure long-

term success

To implement evidence-based and practice-

based programs to improve health amp wellness

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Priority areas are

Tobacco-free living

Active living and healthy eating

Evidence-based quality clinical and other

preventive health services for prevention

and control of high blood pressure and

high cholesterol

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Applicants proposed specific activities in

line with their chosen priority areas in their

applications

Grantee activities will not be finalized until

plans are negotiated with CDC by early

2012

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Capacity-Building Award

The Confederated Tribes of The Chehalis

Reservation is receiving a $498663 planning

award to build capacity to support healthy

lifestyles among their tribal population of 1500

in Washington State

Work will target tobacco-free living active living

and healthy eating and quality clinical and other

healthy serviceswwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Implementation Award

Austin TX Dept of Health and Human Services

is receiving $1026158 to serve Travis County

(Austin) to expand efforts in tobacco-free living

active living and healthy eating quality clinical

and other preventive services social and

emotional wellness and healthy and safe

physical environmentswwwcdcgov1052011

Building sustainable healthy

communities Bottom line

Obesity is an environmental problem

Despite progress in genetic research public health advances only will occur when we take the environment seriously

Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment

Until we do this we will not make substantial progress in addressing the epidemic of obesity

Poston amp Foreyt Atherosclerosis 1999

Whatrsquos the best approach

Integrate all sectors of society into community

change interventions

Incorporate

Science amp Technology

Education

FamilyCommunity

Healthcare

Arts amp Entertainment

Law amp Politics

Commerce amp Trade

Sectors of Society

Arts amp Entertainm

ent

Commerce amp Trade

Education

FamilyCommunity

Healthcare

Law amp Politics

Science amp Technology

Project FIT rationale design and baseline characteristics of a school- and community-

based intervention to address physical activity and healthy eating among low-income

elementary school children

Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D

Oh HJ Orth J Randall S Mayfield K Holmes D

Source

Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu

Abstract

BACKGROUND

This paper describes Project FIT a collaboration between the public school system local

health systems physicians neighborhood associations businesses faith-based leaders

community agencies and university researchers to develop a multi-faceted approach to

promote physical activity and healthy eating toward the general goal of preventing and

reducing childhood obesity among children in Grand Rapids MI USA

METHODSDESIGN

There are four overall components to Project FIT school community social marketing and

school staff wellness - all that focus on 1) increasing access to safe and affordable physical

activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)

improving the affordability and availability of nutritious food in the neighborhoods surrounding

the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding

nutrition and physical activity among school staff parents and students 4) impacting the

culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging

dialogue among all community partners to leverage existing programs and introduce new

ones

DISCRIMINATION

THE PAIN OF OBESITY

Former severely obese patients

100 preferred to be deaf dyslexic

diabetic or have heart disease or bad

acne than to be obese again

Leg amputation was preferred by

915 and blindness by 894

100 preferred to be a normal weight

person rather than a severely obese

multi-millionaire Rand CSW Macgregor AMC Int J Obes 199115577ndash579

Psychosocial Burden of Obesity

Obese individuals often feel misunderstood neglected and rejected

Obese individuals have low employment prospects and are denied educational vocational and advancement opportunities

Significantly poorer quality of life

van Hout GCM van Oudheusden I amp van Heck GL Obes Surg 2004

A Healthy Lifestyle is All About

Balance

Healthy Diet

Healthy Physical Activity

Building Sustainable Healthy

Communities

Healthy Lifestyle

Building Sustainable Healthy

Communities

Healthy Lifestyle

UNFORTUNATELYhellip

Big Texan Steak Ranch

Amarillo Texas

72-oz Steak FREE if eaten within 1 hour

AVERAGE ADULT AMERICAN MAN

Height 5rsquo 8rdquo

Weight 195 lbs

Waist 397 in

BMI 284

CDC 2011

AVERAGE ADULT AMERICAN WOMAN

Height 5rsquo3rdquo

Weight 165 lbs

Waist 370 in

BMI 261

CDC 2011

Miss America

2008

Kirsten Haglund

BMI 1629

Eliana Ramos

Age 18

Height 5rsquo9rdquo

29th OLYMPIAD

BEIJING CHINA

US wrestling team captain Daniel

Cormier (2115 lbs) hospitalized for

kidney failure as result of

dehydration related to cutting weight

(did not compete)

US boxer Gary Russell was found

unconscious 4 days before his

Olympic bout due to cutting weight

(did not compete)

29th OLYMPIAD

BEIJING CHINA

Michael Phelps

8 Gold Medals SwimmingAge 23

Height 6rsquo4rdquo

Weight 195 lbs

BMI 2374

Daily Food Intake 10375 KCAL

(15 PRO 58 CHO 27 FAT)

Exercise 30 hrswk

2005 USDA FOOD PYRAMID

ldquoThe food pyramid

is too complicated

and has too many

messagesrdquo

Robert Post PhD USDA Deputy

Director 2011

2005 USDA FOOD PYRAMID

ldquoItrsquos going to be hard not to do

better than the current pyramid

which basically conveys no

useful informationrdquo

Walter C Willett MD

Chairman Department of Nutrition

Harvard School of Public Health

2011 USDA MY PLATE

ldquoWe are all

bombarded with so

many dietary

messages that it is

hard to find time to

sort through all this

informationrdquo

Michelle Obama 2011

Dietary Guidelines for Americans

2010 Two Primary Concepts

Maintain calorie balance over time to

achieve and maintain a healthy weight

Focus on consuming nutrient-dense foods

and beverages

Dietary Guidelines for Americans 2010

Efficacy-based comparative dietary guidelines

Carb Fat Pro

Mediterranean Diet 45-55 25-35 20

IOM Dietary Ref Intakes 45-65 25-35 15

NCEP-ATPIII 50-60 25-35 15

Am Dietetic Assoc 45-65 20-35 15

PARADOX OF INCREASING OBESITY

PREVALENCE

bull Focus on healthy eating and physical

activity

bull Awareness of dangers of obesity buthellip

bull Obesity prevalence continues to rise

bull Work amp commuting demands

bull Little time to exercise

bull Little time to prepare food

bull Availability of high-fatcalorie foods

Rationale for community-based interventions

bull Increases in obesity prevalence due to genes

bull Increased calories (eg 200 Kcalday

over 10 years)

bull Increased portion sizes (eg 22 oz

steaks and 44 oz sodas)

bull Western diets in developing nations

increase risk of obesity

READINESS TO CHANGE

ldquoHabit is habit and not to be

flung out of the window but

coaxed downstairs a step at a

timerdquo

Mark Twain

Long-Term Weight Maintenance

National Weight Control Registry (N=10000)

Survey of 3000 members who have been in the

Registry for at least 10 years

Starting weight = 224 lbs Average weight loss=69

lbs

At 5 years participants had maintained an average

weight loss=52 lbs

At 10 years participants had maintained an average

weight loss=51 lbs

Thomas Bond Phelan et al TOS 2011

Long-Term Weight Maintenance

Weight Maintainers report that they usually

Track their food intake

Count calories or fat grams

Follow a low-calorie low fat diet (1800 caloriesday

less than 30 of calories from fat

Eat breakfast regularly

Limit the amount they eat out (about 3 timesweek

eat fast food less than onceweek)

Thomas Bond Phelan et al TOS 2011

Long-Term Weight Maintenance

Weight Maintainers report that they usually

Eat similar food regularly

Donrsquot splurge much on holidays amp special occasions

Walk about one hourday

Watch less than 10 hours of TV a week

Weigh themselves at least once a week

Thomas Bond Phelan et al TOS 2011

LONG-TERM WEIGHT MAINTENANCE

Continued consumption of a low-

calorie diet with moderate fat intake

Limited fast food

High levels of physical activity

Phalen et al Obesity 2006 14 710-716

LONG-TERM WEIGHT MAINTENANCE

Daily weighing improved

maintenance of weight loss

particularly when delivered

face to face

Wing et al NEJM 2006 3551563-1571

Most Promising Strategies For

Preventing Weight Regain

Providing multi-component

programs with ongoing

professional contacts

Physical activityexercise

Portion controlmeal replacements

Extending treatment through

weekly or bi-weekly sessions

Pharmacotherapy

Perri Foreyt amp Anton Preventing Weight Regain After Weight Loss 2008

Most Promising Strategies For

Preventing Weight Regain

Extended treatments have shown

promise in promoting adherence to

the behaviors required for the long-

term maintenance of weight loss

Continuous care approach focused

on reasonable long-term objectives

appears appropriate for most

patients

Perri Foreyt amp Anton Preventing Weight Regain After Weight

Loss 2008

An Example of a successful long-term

intervention

The Look AHEAD Study

Does Weight Loss Reduce

Cardiovascular Disease and Death in

Overweight Individuals with Diabetes

bull Action for HEAlth in Diabetes

bull Objective to examine in overweight

persons with Type 2 Diabetes the long-

term effects of an intensive lifestyle

intervention program compared to

diabetes education and support

bull 16 Centers

bull 5145 overweight volunteers with

diabetes

Look AHEAD

Look AHEAD

Primary End Point Composite

bull Cardiovascular death (including fatal

myocardial infarction and stroke)

bull Non-fatal myocardial infarction

bull Non-fatal stroke

Winston-Salem

Baltimore

Philadelphia

New York

Providence

Boston

Clinical Site Coordinating Center

Clinical Sites

Seattle

Los Angeles

San AntonioHouston

Baton Rouge

Minneapolis

Memphis

Birmingham

Pittsburgh

Denver

Phoenix

Look AHEADParticipants

101100Baseline weight (kg)

589586Age (years)

9496Attended 1 year exam

360359Baseline BMI

1514Insulin Users

3737Minority

6059Women

(N=2574)(N=2630)

DSELifestyle

p lt 0004

Look AHEAD

Study Interventions

bull Diabetes support and education - DSE (control group)

bull Lifestyle intervention ndash ILI (treatment group)

Look AHEAD

Lifestyle Intervention

Goals

bull 7 weight loss for the group (10

for individual)

bull 175 minutes of moderate intensity

activity

Look AHEAD

Lifestyle Intervention

bull Diet

ndash ADA NCEP (lt 30 fat lt 10 sat fat

gt15 protein)

ndash 1200-1500 (if weight lt250lbs)

ndash 1500-1800 (if weight gt250lbs)

ndash During first 4 weeks to 4 months portion

control (liquid meal replacements or

structured meal plan)

Look AHEAD

Lifestyle Intervention

bull Physical Activity

ndash unsupervised

ndash 175 minutes moderate intensityweek

ndash 5 daysweek

ndash walking

Weight Loss at 1-Year

-9

ILI 0

-1

-2

-3

-4

-5

-6

-7

-8

DSE

p lt 00001

W

eig

ht

Chan

ge

86

07

The Look AHEAD Research Group Diabetes Care 2007

Reduction in Initial Weight by Gender

N=872

N=1229N=1197

N=830

-12

-10

-8

-6

-4

-2

0

0 2 4 6 8 10 12

Months

R

ed

uctio

n in

In

itia

l W

eig

ht

Men

Women

Plt0001

The Look AHEAD Research Group Diabetes Care 2007

Fitness Change () at 1-Year

0

5

10

15

20

25

Mean

Fitness C

hange

Unadjusted

Plt0001Adjusted for 1 Year

Weight Change Plt0001

58

209

108

159

DSE ILI ILIDSE

The Look AHEAD Research Group Diabetes Care 2007

1-Year Changes in Markers of

Diabetes Control

Markers of Diabetes

Control ILI DSE P-value

Hemoglobin A1c () BL

Hemoglobin A1c () Y1

Y1 ndash Baseline

725

661

-064

729

715

-014

026

lt0001

lt0001

Fasting glucose (mgdl) BL

Fasting glucose (mgdl) Y1

Y1 ndash Baseline

1519

1304

-215

1536

1464

-72

021

lt0001

lt0001

Diabetes medications BL

Diabetes medications Y1

Y1 ndash Baseline

865

786

-78

865

887

22

093

lt0001

lt0001

1-Year Changes in Markers of

Blood Pressure ControlMarkers of Blood Pressure

Control ILI DSE P-value

Systolic BP (mmHg) BL

Systolic BP (mmHg) Y1

Y1 ndash Baseline

1282

1214

-68

1294

1266

-28

026

lt0001

lt0001

Diastolic BP (mmHg) BL

Diastolic BP (mmHg) Y1

Y1 ndash Baseline

699

670

-30

704

686

-18

011

lt0001

lt0001

Antihypertensive medications BL

Antihypertensive medications Y1

Y1 ndash Baseline

753

752

-01

737

759

22

023

054

002

1-Year Changes in Markers of Lipid

Control

Markers of Lipid Control ILI DSE P-value

LDL-cholesterol (mgdl) BL

LDL-cholesterol (mgdl) Y1

Y1 ndash Baseline

1122

1070

-52

1124

1067

-57

078

074

049

HDL-cholesterol (mgdl) BL

HDL-cholesterol (mgdl) Y1

Y1 ndash Baseline

435

469

34

436

449

14

080

lt0001

lt0001

Triglycerides (mgdl) BL

Triglycerides (mgdl) Y1

Y1 ndash Baseline

1828

1525

-303

1800

1654

-146

038

lt0001

lt0001

Lipid lowering medications BL

Lipid lowering medications Y1

Y1 ndash Baseline

494

530

37

484

578

94

052

lt0001

lt0001

1-Year Changes in Percent of Participants

Meeting ADA Goals

ADA Goal ILI DSE P-value

Hemoglobin A1c lt 7 BL

Hemoglobin A1c lt 7 Y1

Y1 ndash Baseline

463

727

264

454

508

54

050

lt0001

lt0001

Blood pressure lt 13080 mmHg BL

Blood pressure lt 13080 mmHg Y1

Y1 ndash Baseline

535

686

151

499

570

70

001

lt0001

lt0001

LDL-cholesterol lt 100 mgdl BL

LDL-cholesterol lt 100 mgdl Y1

Y1 ndash Baseline

371

438

67

369

449

80

087

045

034

All three goals BL

All three goals Y1

Y1 ndash Baseline

108

236

128

95

160

65

013

lt0001

lt0001

Mean Changes in Weight Fitness amp BP

Averaged Over Four Years

DSE

Mean

ILI

Mean

P-value

Weight Loss

( initial wt)

-088 -615 lt 00001

Fitness

( METS)

196 1274 lt00001

HbA1c -009 -036 lt 00001

SBP (mm Hg) -297 -533 lt 00001

DBP (mm Hg) -248 -292 0012

Look AHEAD Research Group Arch Int Med 2010

Mean Changes in Lipid Profile

Averaged Over Four Years

DSE

Mean

ILI

Mean

P-value

HDL (mgdl) 197 367 lt00001

TG (mgdl) -1975 -2556 00006

LDL (mgdl) -1284 -1127 0009

LDL (mgdl)

(Adjusting for

medication use)

-922 -875 042

Look AHEAD Research Group Arch Int Med 2010

Percent () Completing Outcome

Measures at Years 1-4

Intervention Group

(ILI)

Year 1 971

Year 2 949

Year 3 940

Year 4 941

Comparison Group

(DSE)

Year 1 957

Year 2 935

Year 3 938

Year 4 931

Look AHEAD Summary

ILI had significantly greater improvements than DSE in all CVD risk factors averaged across 4 years (except LDL-C)

There may be long-term beneficial effects from this 4-year period in which ILI subjects have been exposed to lower CVD risk factors

Longer follow-ups will determine whether these lowered CVD risk factors can be maintained amp whether lifestyle intervention has positive effects on CVD morbidity amp mortality

Mary J

Female

White

56 years old at start of Look AHEAD

study

Past Medical History Type 2 diabetes

overweight diverticulosis arthritis

sleep apnea back pain

Mary J

bullLong term strugglesbull Helping youngest daughter with

personal issues and children

bull Rotator cuff problems

bull Degenerative disks in back

bull Rheumatoid arthritis

bull Diabetes

bull Physically demanding job

bull Financial struggles

Pounds

Years

82007 grandkids enter pre-school

Catherine L

Female

White

47 years old at start of Look AHEAD

study

Past Medical History Type 2 diabetes

overweight high blood pressure

hypothyroidism back pain

Catherine L

Long term struggles

bull Motherrsquos declining health and death

bull Multiple serious injuries

bull Sudden death of sister

bull Death of step-father

bull Declining economy

bull Children living at home

Pounds

Years

Realistic Management Goals

5-10 weight loss

Health energy and fitness

Well-being and self-esteem

Mood and appearance

Functional and recreational

activity

Key Elements

Focus on health and energy

Food and physical activity diaries

Gradual increase in physical activity

Gradual reduction in dietary fat

No feelings of food deprivation

Social support groups

Recommended Strategies for Building

Sustainable Healthy Communities

Overview from USA

Promote the availability of affordable healthy

food and beverages

Support healthy food and beverage choices

Encourage breastfeeding

Encourage physical activity or limit sedentary

activity among children amp youth

Create safe communities that support physical

activity

Encourage communities to organize for change

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Increase the availability of healthier food and

beverage choices in public service venues (eg

schools city amp county buildings etc)

--Insufficient evidence in school-based programs

--Associations suggest availability amp increased

consumption

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve availability of affordable healthier

food amp beverage choices in public service

venues

--Reducing the cost of healthier foods

increases their purchase

--Providing coupons redeemable for

healthier foods increases their purchase

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve geographic availability of

supermarkets in underserved areas

-- Greater access to nearby supermarkets is

associated with healthier eating behaviors

-- Increasing the number of supermarkets in

underserved neighborhoods increased

real estate values increased economic

activity amp employment amp resulted in lower

food prices

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Provide incentives to food retailers to locate in

andor offer healthier food choices in

underserved areas

-- Presence of retail venues that provide healthier

foods is associated with better nutrition

-- Greater availability of supermarkets was

associated with lower adolescent BMI scores

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Improve availability of mechanisms for

purchasing foods from farms

--Evidence supporting a direct link between

purchasing food from farms amp improved diet is

limited

--Two studies of initiatives to encourage

participation in farmersrsquo market showed

increased intention to eat more fruits amp

vegetables but no direct evidence

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Provide incentives for the production

distribution and procurement of foods from local

farms

--No evidence has been published to link local

food production amp health outcomes

--There is a current study exploring the potential

nutritional amp health benefits of eating locally

grown foods

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Restrict availability of less healthy foods amp

beverages in public service venues

--No peer-reviewed studies examined the impact

designed to restrict availability of less healthy

foods in public service venues

--21 states have policies that restrict the sale of

competitive foods in schools beyond USDA

regulations however no studies have evaluated

the impact of the policies

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Institute smaller portion size options in public

service venues

--Evidence is lacking to demonstrate effectiveness

of population-based interventions aimed at

reducing portion sizes in public service venues

--Evidence from clinical studies in laboratories

demonstrates decreasing portion sizes

decreases energy intake

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Limit advertisements of less healthy foods amp

beverages

--Little evidence is available regarding the impact

of restricting advertising on purchasing amp

consumption of less healthy foods

--Cross-sectional time-series studies of tobacco-

control efforts suggest an association between

advertising bans amp decreased tobacco

consumption

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Discourage consumption of sugar-sweetened

beverages

--One longitudinal study of a school-based

intervention among Native-American high school

students showed a substantial reduction in

sugar-sweetened beverages over a 3-year

period

--A RCT of a home-based intervention that

eliminated sugar-sweetened beverages showed

reduction in BMI scores

Recommended Community Strategies Strategies to encourage breastfeeding

Increase support for breastfeeding

--Evidence directly linking environmental

interventions that support breastfeeding with

obesity-related outcomes is lacking

--Epidemiologic studies indicate that breastfeeding

helps prevent pediatric obesity

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Require physical education in schools

--14 studies have demonstrated that school-based

PE was effective in increasing levels of physical

activity and improving physical fitness

--Minimum of 150 minwk in elementary schools

225 minwk in middle schools and high schools

throughout the school year as recommended by

NASPE

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Increase opportunities for extracurricular

physical activity

--Participation in after-school programs increased

studentsrsquo level of physical activity amp improved

obesity-related outcomes (improved CV fitness

reduced body fat)

--2 pilot studies providing extracurricular physical

activity showed increased levels of PA amp

decreased sedentary behavior

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Reduce screen time in public service venues

--A school-based RCT indicated that children who

reduced their television videotape amp video

game use had significant decrease in BMI tricep

skin fold thickness amp waist circumference

compared to controls

--Spending less time watching television is

associated with increased physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Improve access to outdoor recreational

facilities

--Review of 108 studies indicated that access to facilities

and programs for recreation near their homes amp time

spent outdoors correlated positively with increased

physical activity among childrenamp adults

--Perceptions that footpaths are safe for walking was

significantly associated with adults being classified as

physically active at a level sufficient for health benefits

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting

bicycling

--Longitudinal intervention studies have

demonstrated that improving bicycling

infrastructure is associated with increased

frequency of bicycling

--Cross-sectional studies indicated a significant

association between bicycling infrastructure amp

frequency of biking

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting walking

--Reviews of cross-sectional studies of

environmental correlates of physical activity amp

walking generally find a positive association

between infrastructure supportive of walking amp

physical activity

--Identifying amp creating safe routes to school

together with educational components

increased the number of students walking to

school

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Locating schools within easy walking

distance of residential areas

--Community-scale urban design amp land use policies amp

practices including locating schools stores workplaces

amp recreation areas close to residential areas are

effective in facilitating an increase in levels of physical

activity

--Majority of efforts to encourage walking to school involve

improving the routes rather than improving the location

of schools

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Improve access to public transportation

--Insufficient evidence exists to determine

effectiveness of transportation policies in

increasing the level of physical activity or

improving fitness

--1 study indicated that 29 of individuals who

walk to and from public transit achieve at least

30 minutes of daily physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Zone for mixed-use development

--Allows residential commercial institutional amp

other public land uses to be located in close

proximity to one another

--Studies using correlation analyses amp regression

models indicated that mixed land use was

associated with increased walking amp cycling

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance personal safety in areas where

persons are or could be physically active

--Cross-sectional studies have demonstrated a

negative relationship between crime rates andor

perceived safety amp physical activity in

neighborhoods

--Few intervention studies have evaluated the

impact of policies amp practices to improve

personal safety on physical activity

Geospatial Mapping Linking Urban

Environments to Health Risk

Measure association between environmental variables amp health risk factors

Assess relationships between variables at different levels of analysis

Used in conjunction with linear analyses

Our Community Environmental Model

of Obesity

Community Factors

Poverty

Crime

Grocery Quality

Restaurants

Parks

Sidewalks

Fast Food Outlets

Recreational

Facilities

Individual Factors

Dietary Intake

Physical Activity

Genetics

Family History

StressCoping

Eating Disorders

Psychological

Problems

Weight

Status

Chosen Neighborhoods

Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped

We then matched census-block groups within the income groups by population density and percentage of minority representation

One matched block group per income level was randomly selected

Prevalence of Obesity in

Block-Groups

0

5

10

15

20

25

30

35

40

45

50

Ag

e-a

dju

sted

Ob

esit

y P

rev

ale

nce

(

)

High-Income Low-Income

Age-standardized to the 1990 US Census

Density of Environmental Factors in the

Community Contributes to a ldquoToxicrdquo

Obesity Environment

0

2

4

6

8

10

12

14

16

18

Fast-food Convenience Store Bars

Den

sity

10

00

perso

ns

High-Income Low-Income

COMMUNITYrsquoS PERCEPTION OF SAFETY

0

5

10

15

20

25

30

35

40

Daytime Nighttime

Perc

en

t (

) F

eeli

ng

So

mew

hat

Safe

or

Un

safe

Low-Income High-Income

Percent Substandard (or worse) Housing

or Ground Conditions

of Residential Properties

0

10

20

30

Structural Grounds

Perc

en

t (

)

Low-Income High-Income

CONCLUSIONS

These data suggest that the higher

frequency of outlets providing

calorically-dense foods and alcohol may

contribute to greater obesity prevalence

in residents of low-income communities

More research is needed to thoroughly

document environmental determinants

of health and obesity

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

From 1994-1998 HUD randomly assigned

4498 women with children living in public

housing in high-poverty urban census

tracts to one of three groups (1) housing

vouchers redeemable only if they moved

to a low-poverty census tract (2)

unrestricted vouchers or (3) control group

(no vouchers)

Ludwig et al NEJM 201136516

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

10-12 year follow-up showed modest but

potentially important reductions in the

prevalence of extreme obesity amp diabetes in the

group moving from a neighborhood with high

poverty on one of low poverty compared to the

control group

No differences between the group receiving

traditional vouchers amp the control group

ldquoNeighborhoods matterrdquo

Ludwig et al NEJM 201136516

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance traffic safety in areas where

persons are or could be physically active

--Community-scale urban design amp land use policies to

promote physical activity including design components

to improve street lighting infrastructure projects to

increase safety of pedestrian street crossing and use of

traffic calming approaches such as speed humps amp

traffic circles are effective in increasing physical activity

--Both community-scale amp street-scale policies amp practices

are effective in increasing physical activity

Recommended Community Strategies Encourage Communities to Organize for Change

Participate in community coalitions or

partnerships to address obesity

--Little evidence is available to determine the

impact of community coalitions on obesity

prevention

--The presence of anti-smoking community

coalitions has been associated with lower rates

of tobacco consumption

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

$103 million awarded to 61 states and

communities including state amp local government

agencies tribes amp territories amp state amp local non-

profit organizations

To build capacity to implement changes for

community prevention efforts to ensure long-

term success

To implement evidence-based and practice-

based programs to improve health amp wellness

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Priority areas are

Tobacco-free living

Active living and healthy eating

Evidence-based quality clinical and other

preventive health services for prevention

and control of high blood pressure and

high cholesterol

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Applicants proposed specific activities in

line with their chosen priority areas in their

applications

Grantee activities will not be finalized until

plans are negotiated with CDC by early

2012

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Capacity-Building Award

The Confederated Tribes of The Chehalis

Reservation is receiving a $498663 planning

award to build capacity to support healthy

lifestyles among their tribal population of 1500

in Washington State

Work will target tobacco-free living active living

and healthy eating and quality clinical and other

healthy serviceswwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Implementation Award

Austin TX Dept of Health and Human Services

is receiving $1026158 to serve Travis County

(Austin) to expand efforts in tobacco-free living

active living and healthy eating quality clinical

and other preventive services social and

emotional wellness and healthy and safe

physical environmentswwwcdcgov1052011

Building sustainable healthy

communities Bottom line

Obesity is an environmental problem

Despite progress in genetic research public health advances only will occur when we take the environment seriously

Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment

Until we do this we will not make substantial progress in addressing the epidemic of obesity

Poston amp Foreyt Atherosclerosis 1999

Whatrsquos the best approach

Integrate all sectors of society into community

change interventions

Incorporate

Science amp Technology

Education

FamilyCommunity

Healthcare

Arts amp Entertainment

Law amp Politics

Commerce amp Trade

Sectors of Society

Arts amp Entertainm

ent

Commerce amp Trade

Education

FamilyCommunity

Healthcare

Law amp Politics

Science amp Technology

Project FIT rationale design and baseline characteristics of a school- and community-

based intervention to address physical activity and healthy eating among low-income

elementary school children

Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D

Oh HJ Orth J Randall S Mayfield K Holmes D

Source

Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu

Abstract

BACKGROUND

This paper describes Project FIT a collaboration between the public school system local

health systems physicians neighborhood associations businesses faith-based leaders

community agencies and university researchers to develop a multi-faceted approach to

promote physical activity and healthy eating toward the general goal of preventing and

reducing childhood obesity among children in Grand Rapids MI USA

METHODSDESIGN

There are four overall components to Project FIT school community social marketing and

school staff wellness - all that focus on 1) increasing access to safe and affordable physical

activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)

improving the affordability and availability of nutritious food in the neighborhoods surrounding

the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding

nutrition and physical activity among school staff parents and students 4) impacting the

culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging

dialogue among all community partners to leverage existing programs and introduce new

ones

Psychosocial Burden of Obesity

Obese individuals often feel misunderstood neglected and rejected

Obese individuals have low employment prospects and are denied educational vocational and advancement opportunities

Significantly poorer quality of life

van Hout GCM van Oudheusden I amp van Heck GL Obes Surg 2004

A Healthy Lifestyle is All About

Balance

Healthy Diet

Healthy Physical Activity

Building Sustainable Healthy

Communities

Healthy Lifestyle

Building Sustainable Healthy

Communities

Healthy Lifestyle

UNFORTUNATELYhellip

Big Texan Steak Ranch

Amarillo Texas

72-oz Steak FREE if eaten within 1 hour

AVERAGE ADULT AMERICAN MAN

Height 5rsquo 8rdquo

Weight 195 lbs

Waist 397 in

BMI 284

CDC 2011

AVERAGE ADULT AMERICAN WOMAN

Height 5rsquo3rdquo

Weight 165 lbs

Waist 370 in

BMI 261

CDC 2011

Miss America

2008

Kirsten Haglund

BMI 1629

Eliana Ramos

Age 18

Height 5rsquo9rdquo

29th OLYMPIAD

BEIJING CHINA

US wrestling team captain Daniel

Cormier (2115 lbs) hospitalized for

kidney failure as result of

dehydration related to cutting weight

(did not compete)

US boxer Gary Russell was found

unconscious 4 days before his

Olympic bout due to cutting weight

(did not compete)

29th OLYMPIAD

BEIJING CHINA

Michael Phelps

8 Gold Medals SwimmingAge 23

Height 6rsquo4rdquo

Weight 195 lbs

BMI 2374

Daily Food Intake 10375 KCAL

(15 PRO 58 CHO 27 FAT)

Exercise 30 hrswk

2005 USDA FOOD PYRAMID

ldquoThe food pyramid

is too complicated

and has too many

messagesrdquo

Robert Post PhD USDA Deputy

Director 2011

2005 USDA FOOD PYRAMID

ldquoItrsquos going to be hard not to do

better than the current pyramid

which basically conveys no

useful informationrdquo

Walter C Willett MD

Chairman Department of Nutrition

Harvard School of Public Health

2011 USDA MY PLATE

ldquoWe are all

bombarded with so

many dietary

messages that it is

hard to find time to

sort through all this

informationrdquo

Michelle Obama 2011

Dietary Guidelines for Americans

2010 Two Primary Concepts

Maintain calorie balance over time to

achieve and maintain a healthy weight

Focus on consuming nutrient-dense foods

and beverages

Dietary Guidelines for Americans 2010

Efficacy-based comparative dietary guidelines

Carb Fat Pro

Mediterranean Diet 45-55 25-35 20

IOM Dietary Ref Intakes 45-65 25-35 15

NCEP-ATPIII 50-60 25-35 15

Am Dietetic Assoc 45-65 20-35 15

PARADOX OF INCREASING OBESITY

PREVALENCE

bull Focus on healthy eating and physical

activity

bull Awareness of dangers of obesity buthellip

bull Obesity prevalence continues to rise

bull Work amp commuting demands

bull Little time to exercise

bull Little time to prepare food

bull Availability of high-fatcalorie foods

Rationale for community-based interventions

bull Increases in obesity prevalence due to genes

bull Increased calories (eg 200 Kcalday

over 10 years)

bull Increased portion sizes (eg 22 oz

steaks and 44 oz sodas)

bull Western diets in developing nations

increase risk of obesity

READINESS TO CHANGE

ldquoHabit is habit and not to be

flung out of the window but

coaxed downstairs a step at a

timerdquo

Mark Twain

Long-Term Weight Maintenance

National Weight Control Registry (N=10000)

Survey of 3000 members who have been in the

Registry for at least 10 years

Starting weight = 224 lbs Average weight loss=69

lbs

At 5 years participants had maintained an average

weight loss=52 lbs

At 10 years participants had maintained an average

weight loss=51 lbs

Thomas Bond Phelan et al TOS 2011

Long-Term Weight Maintenance

Weight Maintainers report that they usually

Track their food intake

Count calories or fat grams

Follow a low-calorie low fat diet (1800 caloriesday

less than 30 of calories from fat

Eat breakfast regularly

Limit the amount they eat out (about 3 timesweek

eat fast food less than onceweek)

Thomas Bond Phelan et al TOS 2011

Long-Term Weight Maintenance

Weight Maintainers report that they usually

Eat similar food regularly

Donrsquot splurge much on holidays amp special occasions

Walk about one hourday

Watch less than 10 hours of TV a week

Weigh themselves at least once a week

Thomas Bond Phelan et al TOS 2011

LONG-TERM WEIGHT MAINTENANCE

Continued consumption of a low-

calorie diet with moderate fat intake

Limited fast food

High levels of physical activity

Phalen et al Obesity 2006 14 710-716

LONG-TERM WEIGHT MAINTENANCE

Daily weighing improved

maintenance of weight loss

particularly when delivered

face to face

Wing et al NEJM 2006 3551563-1571

Most Promising Strategies For

Preventing Weight Regain

Providing multi-component

programs with ongoing

professional contacts

Physical activityexercise

Portion controlmeal replacements

Extending treatment through

weekly or bi-weekly sessions

Pharmacotherapy

Perri Foreyt amp Anton Preventing Weight Regain After Weight Loss 2008

Most Promising Strategies For

Preventing Weight Regain

Extended treatments have shown

promise in promoting adherence to

the behaviors required for the long-

term maintenance of weight loss

Continuous care approach focused

on reasonable long-term objectives

appears appropriate for most

patients

Perri Foreyt amp Anton Preventing Weight Regain After Weight

Loss 2008

An Example of a successful long-term

intervention

The Look AHEAD Study

Does Weight Loss Reduce

Cardiovascular Disease and Death in

Overweight Individuals with Diabetes

bull Action for HEAlth in Diabetes

bull Objective to examine in overweight

persons with Type 2 Diabetes the long-

term effects of an intensive lifestyle

intervention program compared to

diabetes education and support

bull 16 Centers

bull 5145 overweight volunteers with

diabetes

Look AHEAD

Look AHEAD

Primary End Point Composite

bull Cardiovascular death (including fatal

myocardial infarction and stroke)

bull Non-fatal myocardial infarction

bull Non-fatal stroke

Winston-Salem

Baltimore

Philadelphia

New York

Providence

Boston

Clinical Site Coordinating Center

Clinical Sites

Seattle

Los Angeles

San AntonioHouston

Baton Rouge

Minneapolis

Memphis

Birmingham

Pittsburgh

Denver

Phoenix

Look AHEADParticipants

101100Baseline weight (kg)

589586Age (years)

9496Attended 1 year exam

360359Baseline BMI

1514Insulin Users

3737Minority

6059Women

(N=2574)(N=2630)

DSELifestyle

p lt 0004

Look AHEAD

Study Interventions

bull Diabetes support and education - DSE (control group)

bull Lifestyle intervention ndash ILI (treatment group)

Look AHEAD

Lifestyle Intervention

Goals

bull 7 weight loss for the group (10

for individual)

bull 175 minutes of moderate intensity

activity

Look AHEAD

Lifestyle Intervention

bull Diet

ndash ADA NCEP (lt 30 fat lt 10 sat fat

gt15 protein)

ndash 1200-1500 (if weight lt250lbs)

ndash 1500-1800 (if weight gt250lbs)

ndash During first 4 weeks to 4 months portion

control (liquid meal replacements or

structured meal plan)

Look AHEAD

Lifestyle Intervention

bull Physical Activity

ndash unsupervised

ndash 175 minutes moderate intensityweek

ndash 5 daysweek

ndash walking

Weight Loss at 1-Year

-9

ILI 0

-1

-2

-3

-4

-5

-6

-7

-8

DSE

p lt 00001

W

eig

ht

Chan

ge

86

07

The Look AHEAD Research Group Diabetes Care 2007

Reduction in Initial Weight by Gender

N=872

N=1229N=1197

N=830

-12

-10

-8

-6

-4

-2

0

0 2 4 6 8 10 12

Months

R

ed

uctio

n in

In

itia

l W

eig

ht

Men

Women

Plt0001

The Look AHEAD Research Group Diabetes Care 2007

Fitness Change () at 1-Year

0

5

10

15

20

25

Mean

Fitness C

hange

Unadjusted

Plt0001Adjusted for 1 Year

Weight Change Plt0001

58

209

108

159

DSE ILI ILIDSE

The Look AHEAD Research Group Diabetes Care 2007

1-Year Changes in Markers of

Diabetes Control

Markers of Diabetes

Control ILI DSE P-value

Hemoglobin A1c () BL

Hemoglobin A1c () Y1

Y1 ndash Baseline

725

661

-064

729

715

-014

026

lt0001

lt0001

Fasting glucose (mgdl) BL

Fasting glucose (mgdl) Y1

Y1 ndash Baseline

1519

1304

-215

1536

1464

-72

021

lt0001

lt0001

Diabetes medications BL

Diabetes medications Y1

Y1 ndash Baseline

865

786

-78

865

887

22

093

lt0001

lt0001

1-Year Changes in Markers of

Blood Pressure ControlMarkers of Blood Pressure

Control ILI DSE P-value

Systolic BP (mmHg) BL

Systolic BP (mmHg) Y1

Y1 ndash Baseline

1282

1214

-68

1294

1266

-28

026

lt0001

lt0001

Diastolic BP (mmHg) BL

Diastolic BP (mmHg) Y1

Y1 ndash Baseline

699

670

-30

704

686

-18

011

lt0001

lt0001

Antihypertensive medications BL

Antihypertensive medications Y1

Y1 ndash Baseline

753

752

-01

737

759

22

023

054

002

1-Year Changes in Markers of Lipid

Control

Markers of Lipid Control ILI DSE P-value

LDL-cholesterol (mgdl) BL

LDL-cholesterol (mgdl) Y1

Y1 ndash Baseline

1122

1070

-52

1124

1067

-57

078

074

049

HDL-cholesterol (mgdl) BL

HDL-cholesterol (mgdl) Y1

Y1 ndash Baseline

435

469

34

436

449

14

080

lt0001

lt0001

Triglycerides (mgdl) BL

Triglycerides (mgdl) Y1

Y1 ndash Baseline

1828

1525

-303

1800

1654

-146

038

lt0001

lt0001

Lipid lowering medications BL

Lipid lowering medications Y1

Y1 ndash Baseline

494

530

37

484

578

94

052

lt0001

lt0001

1-Year Changes in Percent of Participants

Meeting ADA Goals

ADA Goal ILI DSE P-value

Hemoglobin A1c lt 7 BL

Hemoglobin A1c lt 7 Y1

Y1 ndash Baseline

463

727

264

454

508

54

050

lt0001

lt0001

Blood pressure lt 13080 mmHg BL

Blood pressure lt 13080 mmHg Y1

Y1 ndash Baseline

535

686

151

499

570

70

001

lt0001

lt0001

LDL-cholesterol lt 100 mgdl BL

LDL-cholesterol lt 100 mgdl Y1

Y1 ndash Baseline

371

438

67

369

449

80

087

045

034

All three goals BL

All three goals Y1

Y1 ndash Baseline

108

236

128

95

160

65

013

lt0001

lt0001

Mean Changes in Weight Fitness amp BP

Averaged Over Four Years

DSE

Mean

ILI

Mean

P-value

Weight Loss

( initial wt)

-088 -615 lt 00001

Fitness

( METS)

196 1274 lt00001

HbA1c -009 -036 lt 00001

SBP (mm Hg) -297 -533 lt 00001

DBP (mm Hg) -248 -292 0012

Look AHEAD Research Group Arch Int Med 2010

Mean Changes in Lipid Profile

Averaged Over Four Years

DSE

Mean

ILI

Mean

P-value

HDL (mgdl) 197 367 lt00001

TG (mgdl) -1975 -2556 00006

LDL (mgdl) -1284 -1127 0009

LDL (mgdl)

(Adjusting for

medication use)

-922 -875 042

Look AHEAD Research Group Arch Int Med 2010

Percent () Completing Outcome

Measures at Years 1-4

Intervention Group

(ILI)

Year 1 971

Year 2 949

Year 3 940

Year 4 941

Comparison Group

(DSE)

Year 1 957

Year 2 935

Year 3 938

Year 4 931

Look AHEAD Summary

ILI had significantly greater improvements than DSE in all CVD risk factors averaged across 4 years (except LDL-C)

There may be long-term beneficial effects from this 4-year period in which ILI subjects have been exposed to lower CVD risk factors

Longer follow-ups will determine whether these lowered CVD risk factors can be maintained amp whether lifestyle intervention has positive effects on CVD morbidity amp mortality

Mary J

Female

White

56 years old at start of Look AHEAD

study

Past Medical History Type 2 diabetes

overweight diverticulosis arthritis

sleep apnea back pain

Mary J

bullLong term strugglesbull Helping youngest daughter with

personal issues and children

bull Rotator cuff problems

bull Degenerative disks in back

bull Rheumatoid arthritis

bull Diabetes

bull Physically demanding job

bull Financial struggles

Pounds

Years

82007 grandkids enter pre-school

Catherine L

Female

White

47 years old at start of Look AHEAD

study

Past Medical History Type 2 diabetes

overweight high blood pressure

hypothyroidism back pain

Catherine L

Long term struggles

bull Motherrsquos declining health and death

bull Multiple serious injuries

bull Sudden death of sister

bull Death of step-father

bull Declining economy

bull Children living at home

Pounds

Years

Realistic Management Goals

5-10 weight loss

Health energy and fitness

Well-being and self-esteem

Mood and appearance

Functional and recreational

activity

Key Elements

Focus on health and energy

Food and physical activity diaries

Gradual increase in physical activity

Gradual reduction in dietary fat

No feelings of food deprivation

Social support groups

Recommended Strategies for Building

Sustainable Healthy Communities

Overview from USA

Promote the availability of affordable healthy

food and beverages

Support healthy food and beverage choices

Encourage breastfeeding

Encourage physical activity or limit sedentary

activity among children amp youth

Create safe communities that support physical

activity

Encourage communities to organize for change

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Increase the availability of healthier food and

beverage choices in public service venues (eg

schools city amp county buildings etc)

--Insufficient evidence in school-based programs

--Associations suggest availability amp increased

consumption

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve availability of affordable healthier

food amp beverage choices in public service

venues

--Reducing the cost of healthier foods

increases their purchase

--Providing coupons redeemable for

healthier foods increases their purchase

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve geographic availability of

supermarkets in underserved areas

-- Greater access to nearby supermarkets is

associated with healthier eating behaviors

-- Increasing the number of supermarkets in

underserved neighborhoods increased

real estate values increased economic

activity amp employment amp resulted in lower

food prices

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Provide incentives to food retailers to locate in

andor offer healthier food choices in

underserved areas

-- Presence of retail venues that provide healthier

foods is associated with better nutrition

-- Greater availability of supermarkets was

associated with lower adolescent BMI scores

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Improve availability of mechanisms for

purchasing foods from farms

--Evidence supporting a direct link between

purchasing food from farms amp improved diet is

limited

--Two studies of initiatives to encourage

participation in farmersrsquo market showed

increased intention to eat more fruits amp

vegetables but no direct evidence

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Provide incentives for the production

distribution and procurement of foods from local

farms

--No evidence has been published to link local

food production amp health outcomes

--There is a current study exploring the potential

nutritional amp health benefits of eating locally

grown foods

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Restrict availability of less healthy foods amp

beverages in public service venues

--No peer-reviewed studies examined the impact

designed to restrict availability of less healthy

foods in public service venues

--21 states have policies that restrict the sale of

competitive foods in schools beyond USDA

regulations however no studies have evaluated

the impact of the policies

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Institute smaller portion size options in public

service venues

--Evidence is lacking to demonstrate effectiveness

of population-based interventions aimed at

reducing portion sizes in public service venues

--Evidence from clinical studies in laboratories

demonstrates decreasing portion sizes

decreases energy intake

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Limit advertisements of less healthy foods amp

beverages

--Little evidence is available regarding the impact

of restricting advertising on purchasing amp

consumption of less healthy foods

--Cross-sectional time-series studies of tobacco-

control efforts suggest an association between

advertising bans amp decreased tobacco

consumption

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Discourage consumption of sugar-sweetened

beverages

--One longitudinal study of a school-based

intervention among Native-American high school

students showed a substantial reduction in

sugar-sweetened beverages over a 3-year

period

--A RCT of a home-based intervention that

eliminated sugar-sweetened beverages showed

reduction in BMI scores

Recommended Community Strategies Strategies to encourage breastfeeding

Increase support for breastfeeding

--Evidence directly linking environmental

interventions that support breastfeeding with

obesity-related outcomes is lacking

--Epidemiologic studies indicate that breastfeeding

helps prevent pediatric obesity

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Require physical education in schools

--14 studies have demonstrated that school-based

PE was effective in increasing levels of physical

activity and improving physical fitness

--Minimum of 150 minwk in elementary schools

225 minwk in middle schools and high schools

throughout the school year as recommended by

NASPE

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Increase opportunities for extracurricular

physical activity

--Participation in after-school programs increased

studentsrsquo level of physical activity amp improved

obesity-related outcomes (improved CV fitness

reduced body fat)

--2 pilot studies providing extracurricular physical

activity showed increased levels of PA amp

decreased sedentary behavior

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Reduce screen time in public service venues

--A school-based RCT indicated that children who

reduced their television videotape amp video

game use had significant decrease in BMI tricep

skin fold thickness amp waist circumference

compared to controls

--Spending less time watching television is

associated with increased physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Improve access to outdoor recreational

facilities

--Review of 108 studies indicated that access to facilities

and programs for recreation near their homes amp time

spent outdoors correlated positively with increased

physical activity among childrenamp adults

--Perceptions that footpaths are safe for walking was

significantly associated with adults being classified as

physically active at a level sufficient for health benefits

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting

bicycling

--Longitudinal intervention studies have

demonstrated that improving bicycling

infrastructure is associated with increased

frequency of bicycling

--Cross-sectional studies indicated a significant

association between bicycling infrastructure amp

frequency of biking

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting walking

--Reviews of cross-sectional studies of

environmental correlates of physical activity amp

walking generally find a positive association

between infrastructure supportive of walking amp

physical activity

--Identifying amp creating safe routes to school

together with educational components

increased the number of students walking to

school

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Locating schools within easy walking

distance of residential areas

--Community-scale urban design amp land use policies amp

practices including locating schools stores workplaces

amp recreation areas close to residential areas are

effective in facilitating an increase in levels of physical

activity

--Majority of efforts to encourage walking to school involve

improving the routes rather than improving the location

of schools

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Improve access to public transportation

--Insufficient evidence exists to determine

effectiveness of transportation policies in

increasing the level of physical activity or

improving fitness

--1 study indicated that 29 of individuals who

walk to and from public transit achieve at least

30 minutes of daily physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Zone for mixed-use development

--Allows residential commercial institutional amp

other public land uses to be located in close

proximity to one another

--Studies using correlation analyses amp regression

models indicated that mixed land use was

associated with increased walking amp cycling

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance personal safety in areas where

persons are or could be physically active

--Cross-sectional studies have demonstrated a

negative relationship between crime rates andor

perceived safety amp physical activity in

neighborhoods

--Few intervention studies have evaluated the

impact of policies amp practices to improve

personal safety on physical activity

Geospatial Mapping Linking Urban

Environments to Health Risk

Measure association between environmental variables amp health risk factors

Assess relationships between variables at different levels of analysis

Used in conjunction with linear analyses

Our Community Environmental Model

of Obesity

Community Factors

Poverty

Crime

Grocery Quality

Restaurants

Parks

Sidewalks

Fast Food Outlets

Recreational

Facilities

Individual Factors

Dietary Intake

Physical Activity

Genetics

Family History

StressCoping

Eating Disorders

Psychological

Problems

Weight

Status

Chosen Neighborhoods

Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped

We then matched census-block groups within the income groups by population density and percentage of minority representation

One matched block group per income level was randomly selected

Prevalence of Obesity in

Block-Groups

0

5

10

15

20

25

30

35

40

45

50

Ag

e-a

dju

sted

Ob

esit

y P

rev

ale

nce

(

)

High-Income Low-Income

Age-standardized to the 1990 US Census

Density of Environmental Factors in the

Community Contributes to a ldquoToxicrdquo

Obesity Environment

0

2

4

6

8

10

12

14

16

18

Fast-food Convenience Store Bars

Den

sity

10

00

perso

ns

High-Income Low-Income

COMMUNITYrsquoS PERCEPTION OF SAFETY

0

5

10

15

20

25

30

35

40

Daytime Nighttime

Perc

en

t (

) F

eeli

ng

So

mew

hat

Safe

or

Un

safe

Low-Income High-Income

Percent Substandard (or worse) Housing

or Ground Conditions

of Residential Properties

0

10

20

30

Structural Grounds

Perc

en

t (

)

Low-Income High-Income

CONCLUSIONS

These data suggest that the higher

frequency of outlets providing

calorically-dense foods and alcohol may

contribute to greater obesity prevalence

in residents of low-income communities

More research is needed to thoroughly

document environmental determinants

of health and obesity

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

From 1994-1998 HUD randomly assigned

4498 women with children living in public

housing in high-poverty urban census

tracts to one of three groups (1) housing

vouchers redeemable only if they moved

to a low-poverty census tract (2)

unrestricted vouchers or (3) control group

(no vouchers)

Ludwig et al NEJM 201136516

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

10-12 year follow-up showed modest but

potentially important reductions in the

prevalence of extreme obesity amp diabetes in the

group moving from a neighborhood with high

poverty on one of low poverty compared to the

control group

No differences between the group receiving

traditional vouchers amp the control group

ldquoNeighborhoods matterrdquo

Ludwig et al NEJM 201136516

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance traffic safety in areas where

persons are or could be physically active

--Community-scale urban design amp land use policies to

promote physical activity including design components

to improve street lighting infrastructure projects to

increase safety of pedestrian street crossing and use of

traffic calming approaches such as speed humps amp

traffic circles are effective in increasing physical activity

--Both community-scale amp street-scale policies amp practices

are effective in increasing physical activity

Recommended Community Strategies Encourage Communities to Organize for Change

Participate in community coalitions or

partnerships to address obesity

--Little evidence is available to determine the

impact of community coalitions on obesity

prevention

--The presence of anti-smoking community

coalitions has been associated with lower rates

of tobacco consumption

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

$103 million awarded to 61 states and

communities including state amp local government

agencies tribes amp territories amp state amp local non-

profit organizations

To build capacity to implement changes for

community prevention efforts to ensure long-

term success

To implement evidence-based and practice-

based programs to improve health amp wellness

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Priority areas are

Tobacco-free living

Active living and healthy eating

Evidence-based quality clinical and other

preventive health services for prevention

and control of high blood pressure and

high cholesterol

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Applicants proposed specific activities in

line with their chosen priority areas in their

applications

Grantee activities will not be finalized until

plans are negotiated with CDC by early

2012

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Capacity-Building Award

The Confederated Tribes of The Chehalis

Reservation is receiving a $498663 planning

award to build capacity to support healthy

lifestyles among their tribal population of 1500

in Washington State

Work will target tobacco-free living active living

and healthy eating and quality clinical and other

healthy serviceswwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Implementation Award

Austin TX Dept of Health and Human Services

is receiving $1026158 to serve Travis County

(Austin) to expand efforts in tobacco-free living

active living and healthy eating quality clinical

and other preventive services social and

emotional wellness and healthy and safe

physical environmentswwwcdcgov1052011

Building sustainable healthy

communities Bottom line

Obesity is an environmental problem

Despite progress in genetic research public health advances only will occur when we take the environment seriously

Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment

Until we do this we will not make substantial progress in addressing the epidemic of obesity

Poston amp Foreyt Atherosclerosis 1999

Whatrsquos the best approach

Integrate all sectors of society into community

change interventions

Incorporate

Science amp Technology

Education

FamilyCommunity

Healthcare

Arts amp Entertainment

Law amp Politics

Commerce amp Trade

Sectors of Society

Arts amp Entertainm

ent

Commerce amp Trade

Education

FamilyCommunity

Healthcare

Law amp Politics

Science amp Technology

Project FIT rationale design and baseline characteristics of a school- and community-

based intervention to address physical activity and healthy eating among low-income

elementary school children

Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D

Oh HJ Orth J Randall S Mayfield K Holmes D

Source

Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu

Abstract

BACKGROUND

This paper describes Project FIT a collaboration between the public school system local

health systems physicians neighborhood associations businesses faith-based leaders

community agencies and university researchers to develop a multi-faceted approach to

promote physical activity and healthy eating toward the general goal of preventing and

reducing childhood obesity among children in Grand Rapids MI USA

METHODSDESIGN

There are four overall components to Project FIT school community social marketing and

school staff wellness - all that focus on 1) increasing access to safe and affordable physical

activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)

improving the affordability and availability of nutritious food in the neighborhoods surrounding

the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding

nutrition and physical activity among school staff parents and students 4) impacting the

culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging

dialogue among all community partners to leverage existing programs and introduce new

ones

A Healthy Lifestyle is All About

Balance

Healthy Diet

Healthy Physical Activity

Building Sustainable Healthy

Communities

Healthy Lifestyle

Building Sustainable Healthy

Communities

Healthy Lifestyle

UNFORTUNATELYhellip

Big Texan Steak Ranch

Amarillo Texas

72-oz Steak FREE if eaten within 1 hour

AVERAGE ADULT AMERICAN MAN

Height 5rsquo 8rdquo

Weight 195 lbs

Waist 397 in

BMI 284

CDC 2011

AVERAGE ADULT AMERICAN WOMAN

Height 5rsquo3rdquo

Weight 165 lbs

Waist 370 in

BMI 261

CDC 2011

Miss America

2008

Kirsten Haglund

BMI 1629

Eliana Ramos

Age 18

Height 5rsquo9rdquo

29th OLYMPIAD

BEIJING CHINA

US wrestling team captain Daniel

Cormier (2115 lbs) hospitalized for

kidney failure as result of

dehydration related to cutting weight

(did not compete)

US boxer Gary Russell was found

unconscious 4 days before his

Olympic bout due to cutting weight

(did not compete)

29th OLYMPIAD

BEIJING CHINA

Michael Phelps

8 Gold Medals SwimmingAge 23

Height 6rsquo4rdquo

Weight 195 lbs

BMI 2374

Daily Food Intake 10375 KCAL

(15 PRO 58 CHO 27 FAT)

Exercise 30 hrswk

2005 USDA FOOD PYRAMID

ldquoThe food pyramid

is too complicated

and has too many

messagesrdquo

Robert Post PhD USDA Deputy

Director 2011

2005 USDA FOOD PYRAMID

ldquoItrsquos going to be hard not to do

better than the current pyramid

which basically conveys no

useful informationrdquo

Walter C Willett MD

Chairman Department of Nutrition

Harvard School of Public Health

2011 USDA MY PLATE

ldquoWe are all

bombarded with so

many dietary

messages that it is

hard to find time to

sort through all this

informationrdquo

Michelle Obama 2011

Dietary Guidelines for Americans

2010 Two Primary Concepts

Maintain calorie balance over time to

achieve and maintain a healthy weight

Focus on consuming nutrient-dense foods

and beverages

Dietary Guidelines for Americans 2010

Efficacy-based comparative dietary guidelines

Carb Fat Pro

Mediterranean Diet 45-55 25-35 20

IOM Dietary Ref Intakes 45-65 25-35 15

NCEP-ATPIII 50-60 25-35 15

Am Dietetic Assoc 45-65 20-35 15

PARADOX OF INCREASING OBESITY

PREVALENCE

bull Focus on healthy eating and physical

activity

bull Awareness of dangers of obesity buthellip

bull Obesity prevalence continues to rise

bull Work amp commuting demands

bull Little time to exercise

bull Little time to prepare food

bull Availability of high-fatcalorie foods

Rationale for community-based interventions

bull Increases in obesity prevalence due to genes

bull Increased calories (eg 200 Kcalday

over 10 years)

bull Increased portion sizes (eg 22 oz

steaks and 44 oz sodas)

bull Western diets in developing nations

increase risk of obesity

READINESS TO CHANGE

ldquoHabit is habit and not to be

flung out of the window but

coaxed downstairs a step at a

timerdquo

Mark Twain

Long-Term Weight Maintenance

National Weight Control Registry (N=10000)

Survey of 3000 members who have been in the

Registry for at least 10 years

Starting weight = 224 lbs Average weight loss=69

lbs

At 5 years participants had maintained an average

weight loss=52 lbs

At 10 years participants had maintained an average

weight loss=51 lbs

Thomas Bond Phelan et al TOS 2011

Long-Term Weight Maintenance

Weight Maintainers report that they usually

Track their food intake

Count calories or fat grams

Follow a low-calorie low fat diet (1800 caloriesday

less than 30 of calories from fat

Eat breakfast regularly

Limit the amount they eat out (about 3 timesweek

eat fast food less than onceweek)

Thomas Bond Phelan et al TOS 2011

Long-Term Weight Maintenance

Weight Maintainers report that they usually

Eat similar food regularly

Donrsquot splurge much on holidays amp special occasions

Walk about one hourday

Watch less than 10 hours of TV a week

Weigh themselves at least once a week

Thomas Bond Phelan et al TOS 2011

LONG-TERM WEIGHT MAINTENANCE

Continued consumption of a low-

calorie diet with moderate fat intake

Limited fast food

High levels of physical activity

Phalen et al Obesity 2006 14 710-716

LONG-TERM WEIGHT MAINTENANCE

Daily weighing improved

maintenance of weight loss

particularly when delivered

face to face

Wing et al NEJM 2006 3551563-1571

Most Promising Strategies For

Preventing Weight Regain

Providing multi-component

programs with ongoing

professional contacts

Physical activityexercise

Portion controlmeal replacements

Extending treatment through

weekly or bi-weekly sessions

Pharmacotherapy

Perri Foreyt amp Anton Preventing Weight Regain After Weight Loss 2008

Most Promising Strategies For

Preventing Weight Regain

Extended treatments have shown

promise in promoting adherence to

the behaviors required for the long-

term maintenance of weight loss

Continuous care approach focused

on reasonable long-term objectives

appears appropriate for most

patients

Perri Foreyt amp Anton Preventing Weight Regain After Weight

Loss 2008

An Example of a successful long-term

intervention

The Look AHEAD Study

Does Weight Loss Reduce

Cardiovascular Disease and Death in

Overweight Individuals with Diabetes

bull Action for HEAlth in Diabetes

bull Objective to examine in overweight

persons with Type 2 Diabetes the long-

term effects of an intensive lifestyle

intervention program compared to

diabetes education and support

bull 16 Centers

bull 5145 overweight volunteers with

diabetes

Look AHEAD

Look AHEAD

Primary End Point Composite

bull Cardiovascular death (including fatal

myocardial infarction and stroke)

bull Non-fatal myocardial infarction

bull Non-fatal stroke

Winston-Salem

Baltimore

Philadelphia

New York

Providence

Boston

Clinical Site Coordinating Center

Clinical Sites

Seattle

Los Angeles

San AntonioHouston

Baton Rouge

Minneapolis

Memphis

Birmingham

Pittsburgh

Denver

Phoenix

Look AHEADParticipants

101100Baseline weight (kg)

589586Age (years)

9496Attended 1 year exam

360359Baseline BMI

1514Insulin Users

3737Minority

6059Women

(N=2574)(N=2630)

DSELifestyle

p lt 0004

Look AHEAD

Study Interventions

bull Diabetes support and education - DSE (control group)

bull Lifestyle intervention ndash ILI (treatment group)

Look AHEAD

Lifestyle Intervention

Goals

bull 7 weight loss for the group (10

for individual)

bull 175 minutes of moderate intensity

activity

Look AHEAD

Lifestyle Intervention

bull Diet

ndash ADA NCEP (lt 30 fat lt 10 sat fat

gt15 protein)

ndash 1200-1500 (if weight lt250lbs)

ndash 1500-1800 (if weight gt250lbs)

ndash During first 4 weeks to 4 months portion

control (liquid meal replacements or

structured meal plan)

Look AHEAD

Lifestyle Intervention

bull Physical Activity

ndash unsupervised

ndash 175 minutes moderate intensityweek

ndash 5 daysweek

ndash walking

Weight Loss at 1-Year

-9

ILI 0

-1

-2

-3

-4

-5

-6

-7

-8

DSE

p lt 00001

W

eig

ht

Chan

ge

86

07

The Look AHEAD Research Group Diabetes Care 2007

Reduction in Initial Weight by Gender

N=872

N=1229N=1197

N=830

-12

-10

-8

-6

-4

-2

0

0 2 4 6 8 10 12

Months

R

ed

uctio

n in

In

itia

l W

eig

ht

Men

Women

Plt0001

The Look AHEAD Research Group Diabetes Care 2007

Fitness Change () at 1-Year

0

5

10

15

20

25

Mean

Fitness C

hange

Unadjusted

Plt0001Adjusted for 1 Year

Weight Change Plt0001

58

209

108

159

DSE ILI ILIDSE

The Look AHEAD Research Group Diabetes Care 2007

1-Year Changes in Markers of

Diabetes Control

Markers of Diabetes

Control ILI DSE P-value

Hemoglobin A1c () BL

Hemoglobin A1c () Y1

Y1 ndash Baseline

725

661

-064

729

715

-014

026

lt0001

lt0001

Fasting glucose (mgdl) BL

Fasting glucose (mgdl) Y1

Y1 ndash Baseline

1519

1304

-215

1536

1464

-72

021

lt0001

lt0001

Diabetes medications BL

Diabetes medications Y1

Y1 ndash Baseline

865

786

-78

865

887

22

093

lt0001

lt0001

1-Year Changes in Markers of

Blood Pressure ControlMarkers of Blood Pressure

Control ILI DSE P-value

Systolic BP (mmHg) BL

Systolic BP (mmHg) Y1

Y1 ndash Baseline

1282

1214

-68

1294

1266

-28

026

lt0001

lt0001

Diastolic BP (mmHg) BL

Diastolic BP (mmHg) Y1

Y1 ndash Baseline

699

670

-30

704

686

-18

011

lt0001

lt0001

Antihypertensive medications BL

Antihypertensive medications Y1

Y1 ndash Baseline

753

752

-01

737

759

22

023

054

002

1-Year Changes in Markers of Lipid

Control

Markers of Lipid Control ILI DSE P-value

LDL-cholesterol (mgdl) BL

LDL-cholesterol (mgdl) Y1

Y1 ndash Baseline

1122

1070

-52

1124

1067

-57

078

074

049

HDL-cholesterol (mgdl) BL

HDL-cholesterol (mgdl) Y1

Y1 ndash Baseline

435

469

34

436

449

14

080

lt0001

lt0001

Triglycerides (mgdl) BL

Triglycerides (mgdl) Y1

Y1 ndash Baseline

1828

1525

-303

1800

1654

-146

038

lt0001

lt0001

Lipid lowering medications BL

Lipid lowering medications Y1

Y1 ndash Baseline

494

530

37

484

578

94

052

lt0001

lt0001

1-Year Changes in Percent of Participants

Meeting ADA Goals

ADA Goal ILI DSE P-value

Hemoglobin A1c lt 7 BL

Hemoglobin A1c lt 7 Y1

Y1 ndash Baseline

463

727

264

454

508

54

050

lt0001

lt0001

Blood pressure lt 13080 mmHg BL

Blood pressure lt 13080 mmHg Y1

Y1 ndash Baseline

535

686

151

499

570

70

001

lt0001

lt0001

LDL-cholesterol lt 100 mgdl BL

LDL-cholesterol lt 100 mgdl Y1

Y1 ndash Baseline

371

438

67

369

449

80

087

045

034

All three goals BL

All three goals Y1

Y1 ndash Baseline

108

236

128

95

160

65

013

lt0001

lt0001

Mean Changes in Weight Fitness amp BP

Averaged Over Four Years

DSE

Mean

ILI

Mean

P-value

Weight Loss

( initial wt)

-088 -615 lt 00001

Fitness

( METS)

196 1274 lt00001

HbA1c -009 -036 lt 00001

SBP (mm Hg) -297 -533 lt 00001

DBP (mm Hg) -248 -292 0012

Look AHEAD Research Group Arch Int Med 2010

Mean Changes in Lipid Profile

Averaged Over Four Years

DSE

Mean

ILI

Mean

P-value

HDL (mgdl) 197 367 lt00001

TG (mgdl) -1975 -2556 00006

LDL (mgdl) -1284 -1127 0009

LDL (mgdl)

(Adjusting for

medication use)

-922 -875 042

Look AHEAD Research Group Arch Int Med 2010

Percent () Completing Outcome

Measures at Years 1-4

Intervention Group

(ILI)

Year 1 971

Year 2 949

Year 3 940

Year 4 941

Comparison Group

(DSE)

Year 1 957

Year 2 935

Year 3 938

Year 4 931

Look AHEAD Summary

ILI had significantly greater improvements than DSE in all CVD risk factors averaged across 4 years (except LDL-C)

There may be long-term beneficial effects from this 4-year period in which ILI subjects have been exposed to lower CVD risk factors

Longer follow-ups will determine whether these lowered CVD risk factors can be maintained amp whether lifestyle intervention has positive effects on CVD morbidity amp mortality

Mary J

Female

White

56 years old at start of Look AHEAD

study

Past Medical History Type 2 diabetes

overweight diverticulosis arthritis

sleep apnea back pain

Mary J

bullLong term strugglesbull Helping youngest daughter with

personal issues and children

bull Rotator cuff problems

bull Degenerative disks in back

bull Rheumatoid arthritis

bull Diabetes

bull Physically demanding job

bull Financial struggles

Pounds

Years

82007 grandkids enter pre-school

Catherine L

Female

White

47 years old at start of Look AHEAD

study

Past Medical History Type 2 diabetes

overweight high blood pressure

hypothyroidism back pain

Catherine L

Long term struggles

bull Motherrsquos declining health and death

bull Multiple serious injuries

bull Sudden death of sister

bull Death of step-father

bull Declining economy

bull Children living at home

Pounds

Years

Realistic Management Goals

5-10 weight loss

Health energy and fitness

Well-being and self-esteem

Mood and appearance

Functional and recreational

activity

Key Elements

Focus on health and energy

Food and physical activity diaries

Gradual increase in physical activity

Gradual reduction in dietary fat

No feelings of food deprivation

Social support groups

Recommended Strategies for Building

Sustainable Healthy Communities

Overview from USA

Promote the availability of affordable healthy

food and beverages

Support healthy food and beverage choices

Encourage breastfeeding

Encourage physical activity or limit sedentary

activity among children amp youth

Create safe communities that support physical

activity

Encourage communities to organize for change

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Increase the availability of healthier food and

beverage choices in public service venues (eg

schools city amp county buildings etc)

--Insufficient evidence in school-based programs

--Associations suggest availability amp increased

consumption

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve availability of affordable healthier

food amp beverage choices in public service

venues

--Reducing the cost of healthier foods

increases their purchase

--Providing coupons redeemable for

healthier foods increases their purchase

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve geographic availability of

supermarkets in underserved areas

-- Greater access to nearby supermarkets is

associated with healthier eating behaviors

-- Increasing the number of supermarkets in

underserved neighborhoods increased

real estate values increased economic

activity amp employment amp resulted in lower

food prices

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Provide incentives to food retailers to locate in

andor offer healthier food choices in

underserved areas

-- Presence of retail venues that provide healthier

foods is associated with better nutrition

-- Greater availability of supermarkets was

associated with lower adolescent BMI scores

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Improve availability of mechanisms for

purchasing foods from farms

--Evidence supporting a direct link between

purchasing food from farms amp improved diet is

limited

--Two studies of initiatives to encourage

participation in farmersrsquo market showed

increased intention to eat more fruits amp

vegetables but no direct evidence

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Provide incentives for the production

distribution and procurement of foods from local

farms

--No evidence has been published to link local

food production amp health outcomes

--There is a current study exploring the potential

nutritional amp health benefits of eating locally

grown foods

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Restrict availability of less healthy foods amp

beverages in public service venues

--No peer-reviewed studies examined the impact

designed to restrict availability of less healthy

foods in public service venues

--21 states have policies that restrict the sale of

competitive foods in schools beyond USDA

regulations however no studies have evaluated

the impact of the policies

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Institute smaller portion size options in public

service venues

--Evidence is lacking to demonstrate effectiveness

of population-based interventions aimed at

reducing portion sizes in public service venues

--Evidence from clinical studies in laboratories

demonstrates decreasing portion sizes

decreases energy intake

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Limit advertisements of less healthy foods amp

beverages

--Little evidence is available regarding the impact

of restricting advertising on purchasing amp

consumption of less healthy foods

--Cross-sectional time-series studies of tobacco-

control efforts suggest an association between

advertising bans amp decreased tobacco

consumption

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Discourage consumption of sugar-sweetened

beverages

--One longitudinal study of a school-based

intervention among Native-American high school

students showed a substantial reduction in

sugar-sweetened beverages over a 3-year

period

--A RCT of a home-based intervention that

eliminated sugar-sweetened beverages showed

reduction in BMI scores

Recommended Community Strategies Strategies to encourage breastfeeding

Increase support for breastfeeding

--Evidence directly linking environmental

interventions that support breastfeeding with

obesity-related outcomes is lacking

--Epidemiologic studies indicate that breastfeeding

helps prevent pediatric obesity

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Require physical education in schools

--14 studies have demonstrated that school-based

PE was effective in increasing levels of physical

activity and improving physical fitness

--Minimum of 150 minwk in elementary schools

225 minwk in middle schools and high schools

throughout the school year as recommended by

NASPE

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Increase opportunities for extracurricular

physical activity

--Participation in after-school programs increased

studentsrsquo level of physical activity amp improved

obesity-related outcomes (improved CV fitness

reduced body fat)

--2 pilot studies providing extracurricular physical

activity showed increased levels of PA amp

decreased sedentary behavior

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Reduce screen time in public service venues

--A school-based RCT indicated that children who

reduced their television videotape amp video

game use had significant decrease in BMI tricep

skin fold thickness amp waist circumference

compared to controls

--Spending less time watching television is

associated with increased physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Improve access to outdoor recreational

facilities

--Review of 108 studies indicated that access to facilities

and programs for recreation near their homes amp time

spent outdoors correlated positively with increased

physical activity among childrenamp adults

--Perceptions that footpaths are safe for walking was

significantly associated with adults being classified as

physically active at a level sufficient for health benefits

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting

bicycling

--Longitudinal intervention studies have

demonstrated that improving bicycling

infrastructure is associated with increased

frequency of bicycling

--Cross-sectional studies indicated a significant

association between bicycling infrastructure amp

frequency of biking

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting walking

--Reviews of cross-sectional studies of

environmental correlates of physical activity amp

walking generally find a positive association

between infrastructure supportive of walking amp

physical activity

--Identifying amp creating safe routes to school

together with educational components

increased the number of students walking to

school

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Locating schools within easy walking

distance of residential areas

--Community-scale urban design amp land use policies amp

practices including locating schools stores workplaces

amp recreation areas close to residential areas are

effective in facilitating an increase in levels of physical

activity

--Majority of efforts to encourage walking to school involve

improving the routes rather than improving the location

of schools

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Improve access to public transportation

--Insufficient evidence exists to determine

effectiveness of transportation policies in

increasing the level of physical activity or

improving fitness

--1 study indicated that 29 of individuals who

walk to and from public transit achieve at least

30 minutes of daily physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Zone for mixed-use development

--Allows residential commercial institutional amp

other public land uses to be located in close

proximity to one another

--Studies using correlation analyses amp regression

models indicated that mixed land use was

associated with increased walking amp cycling

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance personal safety in areas where

persons are or could be physically active

--Cross-sectional studies have demonstrated a

negative relationship between crime rates andor

perceived safety amp physical activity in

neighborhoods

--Few intervention studies have evaluated the

impact of policies amp practices to improve

personal safety on physical activity

Geospatial Mapping Linking Urban

Environments to Health Risk

Measure association between environmental variables amp health risk factors

Assess relationships between variables at different levels of analysis

Used in conjunction with linear analyses

Our Community Environmental Model

of Obesity

Community Factors

Poverty

Crime

Grocery Quality

Restaurants

Parks

Sidewalks

Fast Food Outlets

Recreational

Facilities

Individual Factors

Dietary Intake

Physical Activity

Genetics

Family History

StressCoping

Eating Disorders

Psychological

Problems

Weight

Status

Chosen Neighborhoods

Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped

We then matched census-block groups within the income groups by population density and percentage of minority representation

One matched block group per income level was randomly selected

Prevalence of Obesity in

Block-Groups

0

5

10

15

20

25

30

35

40

45

50

Ag

e-a

dju

sted

Ob

esit

y P

rev

ale

nce

(

)

High-Income Low-Income

Age-standardized to the 1990 US Census

Density of Environmental Factors in the

Community Contributes to a ldquoToxicrdquo

Obesity Environment

0

2

4

6

8

10

12

14

16

18

Fast-food Convenience Store Bars

Den

sity

10

00

perso

ns

High-Income Low-Income

COMMUNITYrsquoS PERCEPTION OF SAFETY

0

5

10

15

20

25

30

35

40

Daytime Nighttime

Perc

en

t (

) F

eeli

ng

So

mew

hat

Safe

or

Un

safe

Low-Income High-Income

Percent Substandard (or worse) Housing

or Ground Conditions

of Residential Properties

0

10

20

30

Structural Grounds

Perc

en

t (

)

Low-Income High-Income

CONCLUSIONS

These data suggest that the higher

frequency of outlets providing

calorically-dense foods and alcohol may

contribute to greater obesity prevalence

in residents of low-income communities

More research is needed to thoroughly

document environmental determinants

of health and obesity

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

From 1994-1998 HUD randomly assigned

4498 women with children living in public

housing in high-poverty urban census

tracts to one of three groups (1) housing

vouchers redeemable only if they moved

to a low-poverty census tract (2)

unrestricted vouchers or (3) control group

(no vouchers)

Ludwig et al NEJM 201136516

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

10-12 year follow-up showed modest but

potentially important reductions in the

prevalence of extreme obesity amp diabetes in the

group moving from a neighborhood with high

poverty on one of low poverty compared to the

control group

No differences between the group receiving

traditional vouchers amp the control group

ldquoNeighborhoods matterrdquo

Ludwig et al NEJM 201136516

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance traffic safety in areas where

persons are or could be physically active

--Community-scale urban design amp land use policies to

promote physical activity including design components

to improve street lighting infrastructure projects to

increase safety of pedestrian street crossing and use of

traffic calming approaches such as speed humps amp

traffic circles are effective in increasing physical activity

--Both community-scale amp street-scale policies amp practices

are effective in increasing physical activity

Recommended Community Strategies Encourage Communities to Organize for Change

Participate in community coalitions or

partnerships to address obesity

--Little evidence is available to determine the

impact of community coalitions on obesity

prevention

--The presence of anti-smoking community

coalitions has been associated with lower rates

of tobacco consumption

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

$103 million awarded to 61 states and

communities including state amp local government

agencies tribes amp territories amp state amp local non-

profit organizations

To build capacity to implement changes for

community prevention efforts to ensure long-

term success

To implement evidence-based and practice-

based programs to improve health amp wellness

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Priority areas are

Tobacco-free living

Active living and healthy eating

Evidence-based quality clinical and other

preventive health services for prevention

and control of high blood pressure and

high cholesterol

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Applicants proposed specific activities in

line with their chosen priority areas in their

applications

Grantee activities will not be finalized until

plans are negotiated with CDC by early

2012

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Capacity-Building Award

The Confederated Tribes of The Chehalis

Reservation is receiving a $498663 planning

award to build capacity to support healthy

lifestyles among their tribal population of 1500

in Washington State

Work will target tobacco-free living active living

and healthy eating and quality clinical and other

healthy serviceswwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Implementation Award

Austin TX Dept of Health and Human Services

is receiving $1026158 to serve Travis County

(Austin) to expand efforts in tobacco-free living

active living and healthy eating quality clinical

and other preventive services social and

emotional wellness and healthy and safe

physical environmentswwwcdcgov1052011

Building sustainable healthy

communities Bottom line

Obesity is an environmental problem

Despite progress in genetic research public health advances only will occur when we take the environment seriously

Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment

Until we do this we will not make substantial progress in addressing the epidemic of obesity

Poston amp Foreyt Atherosclerosis 1999

Whatrsquos the best approach

Integrate all sectors of society into community

change interventions

Incorporate

Science amp Technology

Education

FamilyCommunity

Healthcare

Arts amp Entertainment

Law amp Politics

Commerce amp Trade

Sectors of Society

Arts amp Entertainm

ent

Commerce amp Trade

Education

FamilyCommunity

Healthcare

Law amp Politics

Science amp Technology

Project FIT rationale design and baseline characteristics of a school- and community-

based intervention to address physical activity and healthy eating among low-income

elementary school children

Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D

Oh HJ Orth J Randall S Mayfield K Holmes D

Source

Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu

Abstract

BACKGROUND

This paper describes Project FIT a collaboration between the public school system local

health systems physicians neighborhood associations businesses faith-based leaders

community agencies and university researchers to develop a multi-faceted approach to

promote physical activity and healthy eating toward the general goal of preventing and

reducing childhood obesity among children in Grand Rapids MI USA

METHODSDESIGN

There are four overall components to Project FIT school community social marketing and

school staff wellness - all that focus on 1) increasing access to safe and affordable physical

activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)

improving the affordability and availability of nutritious food in the neighborhoods surrounding

the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding

nutrition and physical activity among school staff parents and students 4) impacting the

culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging

dialogue among all community partners to leverage existing programs and introduce new

ones

Building Sustainable Healthy

Communities

Healthy Lifestyle

UNFORTUNATELYhellip

Big Texan Steak Ranch

Amarillo Texas

72-oz Steak FREE if eaten within 1 hour

AVERAGE ADULT AMERICAN MAN

Height 5rsquo 8rdquo

Weight 195 lbs

Waist 397 in

BMI 284

CDC 2011

AVERAGE ADULT AMERICAN WOMAN

Height 5rsquo3rdquo

Weight 165 lbs

Waist 370 in

BMI 261

CDC 2011

Miss America

2008

Kirsten Haglund

BMI 1629

Eliana Ramos

Age 18

Height 5rsquo9rdquo

29th OLYMPIAD

BEIJING CHINA

US wrestling team captain Daniel

Cormier (2115 lbs) hospitalized for

kidney failure as result of

dehydration related to cutting weight

(did not compete)

US boxer Gary Russell was found

unconscious 4 days before his

Olympic bout due to cutting weight

(did not compete)

29th OLYMPIAD

BEIJING CHINA

Michael Phelps

8 Gold Medals SwimmingAge 23

Height 6rsquo4rdquo

Weight 195 lbs

BMI 2374

Daily Food Intake 10375 KCAL

(15 PRO 58 CHO 27 FAT)

Exercise 30 hrswk

2005 USDA FOOD PYRAMID

ldquoThe food pyramid

is too complicated

and has too many

messagesrdquo

Robert Post PhD USDA Deputy

Director 2011

2005 USDA FOOD PYRAMID

ldquoItrsquos going to be hard not to do

better than the current pyramid

which basically conveys no

useful informationrdquo

Walter C Willett MD

Chairman Department of Nutrition

Harvard School of Public Health

2011 USDA MY PLATE

ldquoWe are all

bombarded with so

many dietary

messages that it is

hard to find time to

sort through all this

informationrdquo

Michelle Obama 2011

Dietary Guidelines for Americans

2010 Two Primary Concepts

Maintain calorie balance over time to

achieve and maintain a healthy weight

Focus on consuming nutrient-dense foods

and beverages

Dietary Guidelines for Americans 2010

Efficacy-based comparative dietary guidelines

Carb Fat Pro

Mediterranean Diet 45-55 25-35 20

IOM Dietary Ref Intakes 45-65 25-35 15

NCEP-ATPIII 50-60 25-35 15

Am Dietetic Assoc 45-65 20-35 15

PARADOX OF INCREASING OBESITY

PREVALENCE

bull Focus on healthy eating and physical

activity

bull Awareness of dangers of obesity buthellip

bull Obesity prevalence continues to rise

bull Work amp commuting demands

bull Little time to exercise

bull Little time to prepare food

bull Availability of high-fatcalorie foods

Rationale for community-based interventions

bull Increases in obesity prevalence due to genes

bull Increased calories (eg 200 Kcalday

over 10 years)

bull Increased portion sizes (eg 22 oz

steaks and 44 oz sodas)

bull Western diets in developing nations

increase risk of obesity

READINESS TO CHANGE

ldquoHabit is habit and not to be

flung out of the window but

coaxed downstairs a step at a

timerdquo

Mark Twain

Long-Term Weight Maintenance

National Weight Control Registry (N=10000)

Survey of 3000 members who have been in the

Registry for at least 10 years

Starting weight = 224 lbs Average weight loss=69

lbs

At 5 years participants had maintained an average

weight loss=52 lbs

At 10 years participants had maintained an average

weight loss=51 lbs

Thomas Bond Phelan et al TOS 2011

Long-Term Weight Maintenance

Weight Maintainers report that they usually

Track their food intake

Count calories or fat grams

Follow a low-calorie low fat diet (1800 caloriesday

less than 30 of calories from fat

Eat breakfast regularly

Limit the amount they eat out (about 3 timesweek

eat fast food less than onceweek)

Thomas Bond Phelan et al TOS 2011

Long-Term Weight Maintenance

Weight Maintainers report that they usually

Eat similar food regularly

Donrsquot splurge much on holidays amp special occasions

Walk about one hourday

Watch less than 10 hours of TV a week

Weigh themselves at least once a week

Thomas Bond Phelan et al TOS 2011

LONG-TERM WEIGHT MAINTENANCE

Continued consumption of a low-

calorie diet with moderate fat intake

Limited fast food

High levels of physical activity

Phalen et al Obesity 2006 14 710-716

LONG-TERM WEIGHT MAINTENANCE

Daily weighing improved

maintenance of weight loss

particularly when delivered

face to face

Wing et al NEJM 2006 3551563-1571

Most Promising Strategies For

Preventing Weight Regain

Providing multi-component

programs with ongoing

professional contacts

Physical activityexercise

Portion controlmeal replacements

Extending treatment through

weekly or bi-weekly sessions

Pharmacotherapy

Perri Foreyt amp Anton Preventing Weight Regain After Weight Loss 2008

Most Promising Strategies For

Preventing Weight Regain

Extended treatments have shown

promise in promoting adherence to

the behaviors required for the long-

term maintenance of weight loss

Continuous care approach focused

on reasonable long-term objectives

appears appropriate for most

patients

Perri Foreyt amp Anton Preventing Weight Regain After Weight

Loss 2008

An Example of a successful long-term

intervention

The Look AHEAD Study

Does Weight Loss Reduce

Cardiovascular Disease and Death in

Overweight Individuals with Diabetes

bull Action for HEAlth in Diabetes

bull Objective to examine in overweight

persons with Type 2 Diabetes the long-

term effects of an intensive lifestyle

intervention program compared to

diabetes education and support

bull 16 Centers

bull 5145 overweight volunteers with

diabetes

Look AHEAD

Look AHEAD

Primary End Point Composite

bull Cardiovascular death (including fatal

myocardial infarction and stroke)

bull Non-fatal myocardial infarction

bull Non-fatal stroke

Winston-Salem

Baltimore

Philadelphia

New York

Providence

Boston

Clinical Site Coordinating Center

Clinical Sites

Seattle

Los Angeles

San AntonioHouston

Baton Rouge

Minneapolis

Memphis

Birmingham

Pittsburgh

Denver

Phoenix

Look AHEADParticipants

101100Baseline weight (kg)

589586Age (years)

9496Attended 1 year exam

360359Baseline BMI

1514Insulin Users

3737Minority

6059Women

(N=2574)(N=2630)

DSELifestyle

p lt 0004

Look AHEAD

Study Interventions

bull Diabetes support and education - DSE (control group)

bull Lifestyle intervention ndash ILI (treatment group)

Look AHEAD

Lifestyle Intervention

Goals

bull 7 weight loss for the group (10

for individual)

bull 175 minutes of moderate intensity

activity

Look AHEAD

Lifestyle Intervention

bull Diet

ndash ADA NCEP (lt 30 fat lt 10 sat fat

gt15 protein)

ndash 1200-1500 (if weight lt250lbs)

ndash 1500-1800 (if weight gt250lbs)

ndash During first 4 weeks to 4 months portion

control (liquid meal replacements or

structured meal plan)

Look AHEAD

Lifestyle Intervention

bull Physical Activity

ndash unsupervised

ndash 175 minutes moderate intensityweek

ndash 5 daysweek

ndash walking

Weight Loss at 1-Year

-9

ILI 0

-1

-2

-3

-4

-5

-6

-7

-8

DSE

p lt 00001

W

eig

ht

Chan

ge

86

07

The Look AHEAD Research Group Diabetes Care 2007

Reduction in Initial Weight by Gender

N=872

N=1229N=1197

N=830

-12

-10

-8

-6

-4

-2

0

0 2 4 6 8 10 12

Months

R

ed

uctio

n in

In

itia

l W

eig

ht

Men

Women

Plt0001

The Look AHEAD Research Group Diabetes Care 2007

Fitness Change () at 1-Year

0

5

10

15

20

25

Mean

Fitness C

hange

Unadjusted

Plt0001Adjusted for 1 Year

Weight Change Plt0001

58

209

108

159

DSE ILI ILIDSE

The Look AHEAD Research Group Diabetes Care 2007

1-Year Changes in Markers of

Diabetes Control

Markers of Diabetes

Control ILI DSE P-value

Hemoglobin A1c () BL

Hemoglobin A1c () Y1

Y1 ndash Baseline

725

661

-064

729

715

-014

026

lt0001

lt0001

Fasting glucose (mgdl) BL

Fasting glucose (mgdl) Y1

Y1 ndash Baseline

1519

1304

-215

1536

1464

-72

021

lt0001

lt0001

Diabetes medications BL

Diabetes medications Y1

Y1 ndash Baseline

865

786

-78

865

887

22

093

lt0001

lt0001

1-Year Changes in Markers of

Blood Pressure ControlMarkers of Blood Pressure

Control ILI DSE P-value

Systolic BP (mmHg) BL

Systolic BP (mmHg) Y1

Y1 ndash Baseline

1282

1214

-68

1294

1266

-28

026

lt0001

lt0001

Diastolic BP (mmHg) BL

Diastolic BP (mmHg) Y1

Y1 ndash Baseline

699

670

-30

704

686

-18

011

lt0001

lt0001

Antihypertensive medications BL

Antihypertensive medications Y1

Y1 ndash Baseline

753

752

-01

737

759

22

023

054

002

1-Year Changes in Markers of Lipid

Control

Markers of Lipid Control ILI DSE P-value

LDL-cholesterol (mgdl) BL

LDL-cholesterol (mgdl) Y1

Y1 ndash Baseline

1122

1070

-52

1124

1067

-57

078

074

049

HDL-cholesterol (mgdl) BL

HDL-cholesterol (mgdl) Y1

Y1 ndash Baseline

435

469

34

436

449

14

080

lt0001

lt0001

Triglycerides (mgdl) BL

Triglycerides (mgdl) Y1

Y1 ndash Baseline

1828

1525

-303

1800

1654

-146

038

lt0001

lt0001

Lipid lowering medications BL

Lipid lowering medications Y1

Y1 ndash Baseline

494

530

37

484

578

94

052

lt0001

lt0001

1-Year Changes in Percent of Participants

Meeting ADA Goals

ADA Goal ILI DSE P-value

Hemoglobin A1c lt 7 BL

Hemoglobin A1c lt 7 Y1

Y1 ndash Baseline

463

727

264

454

508

54

050

lt0001

lt0001

Blood pressure lt 13080 mmHg BL

Blood pressure lt 13080 mmHg Y1

Y1 ndash Baseline

535

686

151

499

570

70

001

lt0001

lt0001

LDL-cholesterol lt 100 mgdl BL

LDL-cholesterol lt 100 mgdl Y1

Y1 ndash Baseline

371

438

67

369

449

80

087

045

034

All three goals BL

All three goals Y1

Y1 ndash Baseline

108

236

128

95

160

65

013

lt0001

lt0001

Mean Changes in Weight Fitness amp BP

Averaged Over Four Years

DSE

Mean

ILI

Mean

P-value

Weight Loss

( initial wt)

-088 -615 lt 00001

Fitness

( METS)

196 1274 lt00001

HbA1c -009 -036 lt 00001

SBP (mm Hg) -297 -533 lt 00001

DBP (mm Hg) -248 -292 0012

Look AHEAD Research Group Arch Int Med 2010

Mean Changes in Lipid Profile

Averaged Over Four Years

DSE

Mean

ILI

Mean

P-value

HDL (mgdl) 197 367 lt00001

TG (mgdl) -1975 -2556 00006

LDL (mgdl) -1284 -1127 0009

LDL (mgdl)

(Adjusting for

medication use)

-922 -875 042

Look AHEAD Research Group Arch Int Med 2010

Percent () Completing Outcome

Measures at Years 1-4

Intervention Group

(ILI)

Year 1 971

Year 2 949

Year 3 940

Year 4 941

Comparison Group

(DSE)

Year 1 957

Year 2 935

Year 3 938

Year 4 931

Look AHEAD Summary

ILI had significantly greater improvements than DSE in all CVD risk factors averaged across 4 years (except LDL-C)

There may be long-term beneficial effects from this 4-year period in which ILI subjects have been exposed to lower CVD risk factors

Longer follow-ups will determine whether these lowered CVD risk factors can be maintained amp whether lifestyle intervention has positive effects on CVD morbidity amp mortality

Mary J

Female

White

56 years old at start of Look AHEAD

study

Past Medical History Type 2 diabetes

overweight diverticulosis arthritis

sleep apnea back pain

Mary J

bullLong term strugglesbull Helping youngest daughter with

personal issues and children

bull Rotator cuff problems

bull Degenerative disks in back

bull Rheumatoid arthritis

bull Diabetes

bull Physically demanding job

bull Financial struggles

Pounds

Years

82007 grandkids enter pre-school

Catherine L

Female

White

47 years old at start of Look AHEAD

study

Past Medical History Type 2 diabetes

overweight high blood pressure

hypothyroidism back pain

Catherine L

Long term struggles

bull Motherrsquos declining health and death

bull Multiple serious injuries

bull Sudden death of sister

bull Death of step-father

bull Declining economy

bull Children living at home

Pounds

Years

Realistic Management Goals

5-10 weight loss

Health energy and fitness

Well-being and self-esteem

Mood and appearance

Functional and recreational

activity

Key Elements

Focus on health and energy

Food and physical activity diaries

Gradual increase in physical activity

Gradual reduction in dietary fat

No feelings of food deprivation

Social support groups

Recommended Strategies for Building

Sustainable Healthy Communities

Overview from USA

Promote the availability of affordable healthy

food and beverages

Support healthy food and beverage choices

Encourage breastfeeding

Encourage physical activity or limit sedentary

activity among children amp youth

Create safe communities that support physical

activity

Encourage communities to organize for change

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Increase the availability of healthier food and

beverage choices in public service venues (eg

schools city amp county buildings etc)

--Insufficient evidence in school-based programs

--Associations suggest availability amp increased

consumption

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve availability of affordable healthier

food amp beverage choices in public service

venues

--Reducing the cost of healthier foods

increases their purchase

--Providing coupons redeemable for

healthier foods increases their purchase

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve geographic availability of

supermarkets in underserved areas

-- Greater access to nearby supermarkets is

associated with healthier eating behaviors

-- Increasing the number of supermarkets in

underserved neighborhoods increased

real estate values increased economic

activity amp employment amp resulted in lower

food prices

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Provide incentives to food retailers to locate in

andor offer healthier food choices in

underserved areas

-- Presence of retail venues that provide healthier

foods is associated with better nutrition

-- Greater availability of supermarkets was

associated with lower adolescent BMI scores

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Improve availability of mechanisms for

purchasing foods from farms

--Evidence supporting a direct link between

purchasing food from farms amp improved diet is

limited

--Two studies of initiatives to encourage

participation in farmersrsquo market showed

increased intention to eat more fruits amp

vegetables but no direct evidence

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Provide incentives for the production

distribution and procurement of foods from local

farms

--No evidence has been published to link local

food production amp health outcomes

--There is a current study exploring the potential

nutritional amp health benefits of eating locally

grown foods

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Restrict availability of less healthy foods amp

beverages in public service venues

--No peer-reviewed studies examined the impact

designed to restrict availability of less healthy

foods in public service venues

--21 states have policies that restrict the sale of

competitive foods in schools beyond USDA

regulations however no studies have evaluated

the impact of the policies

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Institute smaller portion size options in public

service venues

--Evidence is lacking to demonstrate effectiveness

of population-based interventions aimed at

reducing portion sizes in public service venues

--Evidence from clinical studies in laboratories

demonstrates decreasing portion sizes

decreases energy intake

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Limit advertisements of less healthy foods amp

beverages

--Little evidence is available regarding the impact

of restricting advertising on purchasing amp

consumption of less healthy foods

--Cross-sectional time-series studies of tobacco-

control efforts suggest an association between

advertising bans amp decreased tobacco

consumption

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Discourage consumption of sugar-sweetened

beverages

--One longitudinal study of a school-based

intervention among Native-American high school

students showed a substantial reduction in

sugar-sweetened beverages over a 3-year

period

--A RCT of a home-based intervention that

eliminated sugar-sweetened beverages showed

reduction in BMI scores

Recommended Community Strategies Strategies to encourage breastfeeding

Increase support for breastfeeding

--Evidence directly linking environmental

interventions that support breastfeeding with

obesity-related outcomes is lacking

--Epidemiologic studies indicate that breastfeeding

helps prevent pediatric obesity

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Require physical education in schools

--14 studies have demonstrated that school-based

PE was effective in increasing levels of physical

activity and improving physical fitness

--Minimum of 150 minwk in elementary schools

225 minwk in middle schools and high schools

throughout the school year as recommended by

NASPE

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Increase opportunities for extracurricular

physical activity

--Participation in after-school programs increased

studentsrsquo level of physical activity amp improved

obesity-related outcomes (improved CV fitness

reduced body fat)

--2 pilot studies providing extracurricular physical

activity showed increased levels of PA amp

decreased sedentary behavior

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Reduce screen time in public service venues

--A school-based RCT indicated that children who

reduced their television videotape amp video

game use had significant decrease in BMI tricep

skin fold thickness amp waist circumference

compared to controls

--Spending less time watching television is

associated with increased physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Improve access to outdoor recreational

facilities

--Review of 108 studies indicated that access to facilities

and programs for recreation near their homes amp time

spent outdoors correlated positively with increased

physical activity among childrenamp adults

--Perceptions that footpaths are safe for walking was

significantly associated with adults being classified as

physically active at a level sufficient for health benefits

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting

bicycling

--Longitudinal intervention studies have

demonstrated that improving bicycling

infrastructure is associated with increased

frequency of bicycling

--Cross-sectional studies indicated a significant

association between bicycling infrastructure amp

frequency of biking

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting walking

--Reviews of cross-sectional studies of

environmental correlates of physical activity amp

walking generally find a positive association

between infrastructure supportive of walking amp

physical activity

--Identifying amp creating safe routes to school

together with educational components

increased the number of students walking to

school

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Locating schools within easy walking

distance of residential areas

--Community-scale urban design amp land use policies amp

practices including locating schools stores workplaces

amp recreation areas close to residential areas are

effective in facilitating an increase in levels of physical

activity

--Majority of efforts to encourage walking to school involve

improving the routes rather than improving the location

of schools

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Improve access to public transportation

--Insufficient evidence exists to determine

effectiveness of transportation policies in

increasing the level of physical activity or

improving fitness

--1 study indicated that 29 of individuals who

walk to and from public transit achieve at least

30 minutes of daily physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Zone for mixed-use development

--Allows residential commercial institutional amp

other public land uses to be located in close

proximity to one another

--Studies using correlation analyses amp regression

models indicated that mixed land use was

associated with increased walking amp cycling

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance personal safety in areas where

persons are or could be physically active

--Cross-sectional studies have demonstrated a

negative relationship between crime rates andor

perceived safety amp physical activity in

neighborhoods

--Few intervention studies have evaluated the

impact of policies amp practices to improve

personal safety on physical activity

Geospatial Mapping Linking Urban

Environments to Health Risk

Measure association between environmental variables amp health risk factors

Assess relationships between variables at different levels of analysis

Used in conjunction with linear analyses

Our Community Environmental Model

of Obesity

Community Factors

Poverty

Crime

Grocery Quality

Restaurants

Parks

Sidewalks

Fast Food Outlets

Recreational

Facilities

Individual Factors

Dietary Intake

Physical Activity

Genetics

Family History

StressCoping

Eating Disorders

Psychological

Problems

Weight

Status

Chosen Neighborhoods

Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped

We then matched census-block groups within the income groups by population density and percentage of minority representation

One matched block group per income level was randomly selected

Prevalence of Obesity in

Block-Groups

0

5

10

15

20

25

30

35

40

45

50

Ag

e-a

dju

sted

Ob

esit

y P

rev

ale

nce

(

)

High-Income Low-Income

Age-standardized to the 1990 US Census

Density of Environmental Factors in the

Community Contributes to a ldquoToxicrdquo

Obesity Environment

0

2

4

6

8

10

12

14

16

18

Fast-food Convenience Store Bars

Den

sity

10

00

perso

ns

High-Income Low-Income

COMMUNITYrsquoS PERCEPTION OF SAFETY

0

5

10

15

20

25

30

35

40

Daytime Nighttime

Perc

en

t (

) F

eeli

ng

So

mew

hat

Safe

or

Un

safe

Low-Income High-Income

Percent Substandard (or worse) Housing

or Ground Conditions

of Residential Properties

0

10

20

30

Structural Grounds

Perc

en

t (

)

Low-Income High-Income

CONCLUSIONS

These data suggest that the higher

frequency of outlets providing

calorically-dense foods and alcohol may

contribute to greater obesity prevalence

in residents of low-income communities

More research is needed to thoroughly

document environmental determinants

of health and obesity

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

From 1994-1998 HUD randomly assigned

4498 women with children living in public

housing in high-poverty urban census

tracts to one of three groups (1) housing

vouchers redeemable only if they moved

to a low-poverty census tract (2)

unrestricted vouchers or (3) control group

(no vouchers)

Ludwig et al NEJM 201136516

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

10-12 year follow-up showed modest but

potentially important reductions in the

prevalence of extreme obesity amp diabetes in the

group moving from a neighborhood with high

poverty on one of low poverty compared to the

control group

No differences between the group receiving

traditional vouchers amp the control group

ldquoNeighborhoods matterrdquo

Ludwig et al NEJM 201136516

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance traffic safety in areas where

persons are or could be physically active

--Community-scale urban design amp land use policies to

promote physical activity including design components

to improve street lighting infrastructure projects to

increase safety of pedestrian street crossing and use of

traffic calming approaches such as speed humps amp

traffic circles are effective in increasing physical activity

--Both community-scale amp street-scale policies amp practices

are effective in increasing physical activity

Recommended Community Strategies Encourage Communities to Organize for Change

Participate in community coalitions or

partnerships to address obesity

--Little evidence is available to determine the

impact of community coalitions on obesity

prevention

--The presence of anti-smoking community

coalitions has been associated with lower rates

of tobacco consumption

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

$103 million awarded to 61 states and

communities including state amp local government

agencies tribes amp territories amp state amp local non-

profit organizations

To build capacity to implement changes for

community prevention efforts to ensure long-

term success

To implement evidence-based and practice-

based programs to improve health amp wellness

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Priority areas are

Tobacco-free living

Active living and healthy eating

Evidence-based quality clinical and other

preventive health services for prevention

and control of high blood pressure and

high cholesterol

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Applicants proposed specific activities in

line with their chosen priority areas in their

applications

Grantee activities will not be finalized until

plans are negotiated with CDC by early

2012

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Capacity-Building Award

The Confederated Tribes of The Chehalis

Reservation is receiving a $498663 planning

award to build capacity to support healthy

lifestyles among their tribal population of 1500

in Washington State

Work will target tobacco-free living active living

and healthy eating and quality clinical and other

healthy serviceswwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Implementation Award

Austin TX Dept of Health and Human Services

is receiving $1026158 to serve Travis County

(Austin) to expand efforts in tobacco-free living

active living and healthy eating quality clinical

and other preventive services social and

emotional wellness and healthy and safe

physical environmentswwwcdcgov1052011

Building sustainable healthy

communities Bottom line

Obesity is an environmental problem

Despite progress in genetic research public health advances only will occur when we take the environment seriously

Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment

Until we do this we will not make substantial progress in addressing the epidemic of obesity

Poston amp Foreyt Atherosclerosis 1999

Whatrsquos the best approach

Integrate all sectors of society into community

change interventions

Incorporate

Science amp Technology

Education

FamilyCommunity

Healthcare

Arts amp Entertainment

Law amp Politics

Commerce amp Trade

Sectors of Society

Arts amp Entertainm

ent

Commerce amp Trade

Education

FamilyCommunity

Healthcare

Law amp Politics

Science amp Technology

Project FIT rationale design and baseline characteristics of a school- and community-

based intervention to address physical activity and healthy eating among low-income

elementary school children

Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D

Oh HJ Orth J Randall S Mayfield K Holmes D

Source

Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu

Abstract

BACKGROUND

This paper describes Project FIT a collaboration between the public school system local

health systems physicians neighborhood associations businesses faith-based leaders

community agencies and university researchers to develop a multi-faceted approach to

promote physical activity and healthy eating toward the general goal of preventing and

reducing childhood obesity among children in Grand Rapids MI USA

METHODSDESIGN

There are four overall components to Project FIT school community social marketing and

school staff wellness - all that focus on 1) increasing access to safe and affordable physical

activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)

improving the affordability and availability of nutritious food in the neighborhoods surrounding

the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding

nutrition and physical activity among school staff parents and students 4) impacting the

culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging

dialogue among all community partners to leverage existing programs and introduce new

ones

Big Texan Steak Ranch

Amarillo Texas

72-oz Steak FREE if eaten within 1 hour

AVERAGE ADULT AMERICAN MAN

Height 5rsquo 8rdquo

Weight 195 lbs

Waist 397 in

BMI 284

CDC 2011

AVERAGE ADULT AMERICAN WOMAN

Height 5rsquo3rdquo

Weight 165 lbs

Waist 370 in

BMI 261

CDC 2011

Miss America

2008

Kirsten Haglund

BMI 1629

Eliana Ramos

Age 18

Height 5rsquo9rdquo

29th OLYMPIAD

BEIJING CHINA

US wrestling team captain Daniel

Cormier (2115 lbs) hospitalized for

kidney failure as result of

dehydration related to cutting weight

(did not compete)

US boxer Gary Russell was found

unconscious 4 days before his

Olympic bout due to cutting weight

(did not compete)

29th OLYMPIAD

BEIJING CHINA

Michael Phelps

8 Gold Medals SwimmingAge 23

Height 6rsquo4rdquo

Weight 195 lbs

BMI 2374

Daily Food Intake 10375 KCAL

(15 PRO 58 CHO 27 FAT)

Exercise 30 hrswk

2005 USDA FOOD PYRAMID

ldquoThe food pyramid

is too complicated

and has too many

messagesrdquo

Robert Post PhD USDA Deputy

Director 2011

2005 USDA FOOD PYRAMID

ldquoItrsquos going to be hard not to do

better than the current pyramid

which basically conveys no

useful informationrdquo

Walter C Willett MD

Chairman Department of Nutrition

Harvard School of Public Health

2011 USDA MY PLATE

ldquoWe are all

bombarded with so

many dietary

messages that it is

hard to find time to

sort through all this

informationrdquo

Michelle Obama 2011

Dietary Guidelines for Americans

2010 Two Primary Concepts

Maintain calorie balance over time to

achieve and maintain a healthy weight

Focus on consuming nutrient-dense foods

and beverages

Dietary Guidelines for Americans 2010

Efficacy-based comparative dietary guidelines

Carb Fat Pro

Mediterranean Diet 45-55 25-35 20

IOM Dietary Ref Intakes 45-65 25-35 15

NCEP-ATPIII 50-60 25-35 15

Am Dietetic Assoc 45-65 20-35 15

PARADOX OF INCREASING OBESITY

PREVALENCE

bull Focus on healthy eating and physical

activity

bull Awareness of dangers of obesity buthellip

bull Obesity prevalence continues to rise

bull Work amp commuting demands

bull Little time to exercise

bull Little time to prepare food

bull Availability of high-fatcalorie foods

Rationale for community-based interventions

bull Increases in obesity prevalence due to genes

bull Increased calories (eg 200 Kcalday

over 10 years)

bull Increased portion sizes (eg 22 oz

steaks and 44 oz sodas)

bull Western diets in developing nations

increase risk of obesity

READINESS TO CHANGE

ldquoHabit is habit and not to be

flung out of the window but

coaxed downstairs a step at a

timerdquo

Mark Twain

Long-Term Weight Maintenance

National Weight Control Registry (N=10000)

Survey of 3000 members who have been in the

Registry for at least 10 years

Starting weight = 224 lbs Average weight loss=69

lbs

At 5 years participants had maintained an average

weight loss=52 lbs

At 10 years participants had maintained an average

weight loss=51 lbs

Thomas Bond Phelan et al TOS 2011

Long-Term Weight Maintenance

Weight Maintainers report that they usually

Track their food intake

Count calories or fat grams

Follow a low-calorie low fat diet (1800 caloriesday

less than 30 of calories from fat

Eat breakfast regularly

Limit the amount they eat out (about 3 timesweek

eat fast food less than onceweek)

Thomas Bond Phelan et al TOS 2011

Long-Term Weight Maintenance

Weight Maintainers report that they usually

Eat similar food regularly

Donrsquot splurge much on holidays amp special occasions

Walk about one hourday

Watch less than 10 hours of TV a week

Weigh themselves at least once a week

Thomas Bond Phelan et al TOS 2011

LONG-TERM WEIGHT MAINTENANCE

Continued consumption of a low-

calorie diet with moderate fat intake

Limited fast food

High levels of physical activity

Phalen et al Obesity 2006 14 710-716

LONG-TERM WEIGHT MAINTENANCE

Daily weighing improved

maintenance of weight loss

particularly when delivered

face to face

Wing et al NEJM 2006 3551563-1571

Most Promising Strategies For

Preventing Weight Regain

Providing multi-component

programs with ongoing

professional contacts

Physical activityexercise

Portion controlmeal replacements

Extending treatment through

weekly or bi-weekly sessions

Pharmacotherapy

Perri Foreyt amp Anton Preventing Weight Regain After Weight Loss 2008

Most Promising Strategies For

Preventing Weight Regain

Extended treatments have shown

promise in promoting adherence to

the behaviors required for the long-

term maintenance of weight loss

Continuous care approach focused

on reasonable long-term objectives

appears appropriate for most

patients

Perri Foreyt amp Anton Preventing Weight Regain After Weight

Loss 2008

An Example of a successful long-term

intervention

The Look AHEAD Study

Does Weight Loss Reduce

Cardiovascular Disease and Death in

Overweight Individuals with Diabetes

bull Action for HEAlth in Diabetes

bull Objective to examine in overweight

persons with Type 2 Diabetes the long-

term effects of an intensive lifestyle

intervention program compared to

diabetes education and support

bull 16 Centers

bull 5145 overweight volunteers with

diabetes

Look AHEAD

Look AHEAD

Primary End Point Composite

bull Cardiovascular death (including fatal

myocardial infarction and stroke)

bull Non-fatal myocardial infarction

bull Non-fatal stroke

Winston-Salem

Baltimore

Philadelphia

New York

Providence

Boston

Clinical Site Coordinating Center

Clinical Sites

Seattle

Los Angeles

San AntonioHouston

Baton Rouge

Minneapolis

Memphis

Birmingham

Pittsburgh

Denver

Phoenix

Look AHEADParticipants

101100Baseline weight (kg)

589586Age (years)

9496Attended 1 year exam

360359Baseline BMI

1514Insulin Users

3737Minority

6059Women

(N=2574)(N=2630)

DSELifestyle

p lt 0004

Look AHEAD

Study Interventions

bull Diabetes support and education - DSE (control group)

bull Lifestyle intervention ndash ILI (treatment group)

Look AHEAD

Lifestyle Intervention

Goals

bull 7 weight loss for the group (10

for individual)

bull 175 minutes of moderate intensity

activity

Look AHEAD

Lifestyle Intervention

bull Diet

ndash ADA NCEP (lt 30 fat lt 10 sat fat

gt15 protein)

ndash 1200-1500 (if weight lt250lbs)

ndash 1500-1800 (if weight gt250lbs)

ndash During first 4 weeks to 4 months portion

control (liquid meal replacements or

structured meal plan)

Look AHEAD

Lifestyle Intervention

bull Physical Activity

ndash unsupervised

ndash 175 minutes moderate intensityweek

ndash 5 daysweek

ndash walking

Weight Loss at 1-Year

-9

ILI 0

-1

-2

-3

-4

-5

-6

-7

-8

DSE

p lt 00001

W

eig

ht

Chan

ge

86

07

The Look AHEAD Research Group Diabetes Care 2007

Reduction in Initial Weight by Gender

N=872

N=1229N=1197

N=830

-12

-10

-8

-6

-4

-2

0

0 2 4 6 8 10 12

Months

R

ed

uctio

n in

In

itia

l W

eig

ht

Men

Women

Plt0001

The Look AHEAD Research Group Diabetes Care 2007

Fitness Change () at 1-Year

0

5

10

15

20

25

Mean

Fitness C

hange

Unadjusted

Plt0001Adjusted for 1 Year

Weight Change Plt0001

58

209

108

159

DSE ILI ILIDSE

The Look AHEAD Research Group Diabetes Care 2007

1-Year Changes in Markers of

Diabetes Control

Markers of Diabetes

Control ILI DSE P-value

Hemoglobin A1c () BL

Hemoglobin A1c () Y1

Y1 ndash Baseline

725

661

-064

729

715

-014

026

lt0001

lt0001

Fasting glucose (mgdl) BL

Fasting glucose (mgdl) Y1

Y1 ndash Baseline

1519

1304

-215

1536

1464

-72

021

lt0001

lt0001

Diabetes medications BL

Diabetes medications Y1

Y1 ndash Baseline

865

786

-78

865

887

22

093

lt0001

lt0001

1-Year Changes in Markers of

Blood Pressure ControlMarkers of Blood Pressure

Control ILI DSE P-value

Systolic BP (mmHg) BL

Systolic BP (mmHg) Y1

Y1 ndash Baseline

1282

1214

-68

1294

1266

-28

026

lt0001

lt0001

Diastolic BP (mmHg) BL

Diastolic BP (mmHg) Y1

Y1 ndash Baseline

699

670

-30

704

686

-18

011

lt0001

lt0001

Antihypertensive medications BL

Antihypertensive medications Y1

Y1 ndash Baseline

753

752

-01

737

759

22

023

054

002

1-Year Changes in Markers of Lipid

Control

Markers of Lipid Control ILI DSE P-value

LDL-cholesterol (mgdl) BL

LDL-cholesterol (mgdl) Y1

Y1 ndash Baseline

1122

1070

-52

1124

1067

-57

078

074

049

HDL-cholesterol (mgdl) BL

HDL-cholesterol (mgdl) Y1

Y1 ndash Baseline

435

469

34

436

449

14

080

lt0001

lt0001

Triglycerides (mgdl) BL

Triglycerides (mgdl) Y1

Y1 ndash Baseline

1828

1525

-303

1800

1654

-146

038

lt0001

lt0001

Lipid lowering medications BL

Lipid lowering medications Y1

Y1 ndash Baseline

494

530

37

484

578

94

052

lt0001

lt0001

1-Year Changes in Percent of Participants

Meeting ADA Goals

ADA Goal ILI DSE P-value

Hemoglobin A1c lt 7 BL

Hemoglobin A1c lt 7 Y1

Y1 ndash Baseline

463

727

264

454

508

54

050

lt0001

lt0001

Blood pressure lt 13080 mmHg BL

Blood pressure lt 13080 mmHg Y1

Y1 ndash Baseline

535

686

151

499

570

70

001

lt0001

lt0001

LDL-cholesterol lt 100 mgdl BL

LDL-cholesterol lt 100 mgdl Y1

Y1 ndash Baseline

371

438

67

369

449

80

087

045

034

All three goals BL

All three goals Y1

Y1 ndash Baseline

108

236

128

95

160

65

013

lt0001

lt0001

Mean Changes in Weight Fitness amp BP

Averaged Over Four Years

DSE

Mean

ILI

Mean

P-value

Weight Loss

( initial wt)

-088 -615 lt 00001

Fitness

( METS)

196 1274 lt00001

HbA1c -009 -036 lt 00001

SBP (mm Hg) -297 -533 lt 00001

DBP (mm Hg) -248 -292 0012

Look AHEAD Research Group Arch Int Med 2010

Mean Changes in Lipid Profile

Averaged Over Four Years

DSE

Mean

ILI

Mean

P-value

HDL (mgdl) 197 367 lt00001

TG (mgdl) -1975 -2556 00006

LDL (mgdl) -1284 -1127 0009

LDL (mgdl)

(Adjusting for

medication use)

-922 -875 042

Look AHEAD Research Group Arch Int Med 2010

Percent () Completing Outcome

Measures at Years 1-4

Intervention Group

(ILI)

Year 1 971

Year 2 949

Year 3 940

Year 4 941

Comparison Group

(DSE)

Year 1 957

Year 2 935

Year 3 938

Year 4 931

Look AHEAD Summary

ILI had significantly greater improvements than DSE in all CVD risk factors averaged across 4 years (except LDL-C)

There may be long-term beneficial effects from this 4-year period in which ILI subjects have been exposed to lower CVD risk factors

Longer follow-ups will determine whether these lowered CVD risk factors can be maintained amp whether lifestyle intervention has positive effects on CVD morbidity amp mortality

Mary J

Female

White

56 years old at start of Look AHEAD

study

Past Medical History Type 2 diabetes

overweight diverticulosis arthritis

sleep apnea back pain

Mary J

bullLong term strugglesbull Helping youngest daughter with

personal issues and children

bull Rotator cuff problems

bull Degenerative disks in back

bull Rheumatoid arthritis

bull Diabetes

bull Physically demanding job

bull Financial struggles

Pounds

Years

82007 grandkids enter pre-school

Catherine L

Female

White

47 years old at start of Look AHEAD

study

Past Medical History Type 2 diabetes

overweight high blood pressure

hypothyroidism back pain

Catherine L

Long term struggles

bull Motherrsquos declining health and death

bull Multiple serious injuries

bull Sudden death of sister

bull Death of step-father

bull Declining economy

bull Children living at home

Pounds

Years

Realistic Management Goals

5-10 weight loss

Health energy and fitness

Well-being and self-esteem

Mood and appearance

Functional and recreational

activity

Key Elements

Focus on health and energy

Food and physical activity diaries

Gradual increase in physical activity

Gradual reduction in dietary fat

No feelings of food deprivation

Social support groups

Recommended Strategies for Building

Sustainable Healthy Communities

Overview from USA

Promote the availability of affordable healthy

food and beverages

Support healthy food and beverage choices

Encourage breastfeeding

Encourage physical activity or limit sedentary

activity among children amp youth

Create safe communities that support physical

activity

Encourage communities to organize for change

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Increase the availability of healthier food and

beverage choices in public service venues (eg

schools city amp county buildings etc)

--Insufficient evidence in school-based programs

--Associations suggest availability amp increased

consumption

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve availability of affordable healthier

food amp beverage choices in public service

venues

--Reducing the cost of healthier foods

increases their purchase

--Providing coupons redeemable for

healthier foods increases their purchase

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve geographic availability of

supermarkets in underserved areas

-- Greater access to nearby supermarkets is

associated with healthier eating behaviors

-- Increasing the number of supermarkets in

underserved neighborhoods increased

real estate values increased economic

activity amp employment amp resulted in lower

food prices

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Provide incentives to food retailers to locate in

andor offer healthier food choices in

underserved areas

-- Presence of retail venues that provide healthier

foods is associated with better nutrition

-- Greater availability of supermarkets was

associated with lower adolescent BMI scores

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Improve availability of mechanisms for

purchasing foods from farms

--Evidence supporting a direct link between

purchasing food from farms amp improved diet is

limited

--Two studies of initiatives to encourage

participation in farmersrsquo market showed

increased intention to eat more fruits amp

vegetables but no direct evidence

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Provide incentives for the production

distribution and procurement of foods from local

farms

--No evidence has been published to link local

food production amp health outcomes

--There is a current study exploring the potential

nutritional amp health benefits of eating locally

grown foods

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Restrict availability of less healthy foods amp

beverages in public service venues

--No peer-reviewed studies examined the impact

designed to restrict availability of less healthy

foods in public service venues

--21 states have policies that restrict the sale of

competitive foods in schools beyond USDA

regulations however no studies have evaluated

the impact of the policies

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Institute smaller portion size options in public

service venues

--Evidence is lacking to demonstrate effectiveness

of population-based interventions aimed at

reducing portion sizes in public service venues

--Evidence from clinical studies in laboratories

demonstrates decreasing portion sizes

decreases energy intake

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Limit advertisements of less healthy foods amp

beverages

--Little evidence is available regarding the impact

of restricting advertising on purchasing amp

consumption of less healthy foods

--Cross-sectional time-series studies of tobacco-

control efforts suggest an association between

advertising bans amp decreased tobacco

consumption

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Discourage consumption of sugar-sweetened

beverages

--One longitudinal study of a school-based

intervention among Native-American high school

students showed a substantial reduction in

sugar-sweetened beverages over a 3-year

period

--A RCT of a home-based intervention that

eliminated sugar-sweetened beverages showed

reduction in BMI scores

Recommended Community Strategies Strategies to encourage breastfeeding

Increase support for breastfeeding

--Evidence directly linking environmental

interventions that support breastfeeding with

obesity-related outcomes is lacking

--Epidemiologic studies indicate that breastfeeding

helps prevent pediatric obesity

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Require physical education in schools

--14 studies have demonstrated that school-based

PE was effective in increasing levels of physical

activity and improving physical fitness

--Minimum of 150 minwk in elementary schools

225 minwk in middle schools and high schools

throughout the school year as recommended by

NASPE

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Increase opportunities for extracurricular

physical activity

--Participation in after-school programs increased

studentsrsquo level of physical activity amp improved

obesity-related outcomes (improved CV fitness

reduced body fat)

--2 pilot studies providing extracurricular physical

activity showed increased levels of PA amp

decreased sedentary behavior

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Reduce screen time in public service venues

--A school-based RCT indicated that children who

reduced their television videotape amp video

game use had significant decrease in BMI tricep

skin fold thickness amp waist circumference

compared to controls

--Spending less time watching television is

associated with increased physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Improve access to outdoor recreational

facilities

--Review of 108 studies indicated that access to facilities

and programs for recreation near their homes amp time

spent outdoors correlated positively with increased

physical activity among childrenamp adults

--Perceptions that footpaths are safe for walking was

significantly associated with adults being classified as

physically active at a level sufficient for health benefits

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting

bicycling

--Longitudinal intervention studies have

demonstrated that improving bicycling

infrastructure is associated with increased

frequency of bicycling

--Cross-sectional studies indicated a significant

association between bicycling infrastructure amp

frequency of biking

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting walking

--Reviews of cross-sectional studies of

environmental correlates of physical activity amp

walking generally find a positive association

between infrastructure supportive of walking amp

physical activity

--Identifying amp creating safe routes to school

together with educational components

increased the number of students walking to

school

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Locating schools within easy walking

distance of residential areas

--Community-scale urban design amp land use policies amp

practices including locating schools stores workplaces

amp recreation areas close to residential areas are

effective in facilitating an increase in levels of physical

activity

--Majority of efforts to encourage walking to school involve

improving the routes rather than improving the location

of schools

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Improve access to public transportation

--Insufficient evidence exists to determine

effectiveness of transportation policies in

increasing the level of physical activity or

improving fitness

--1 study indicated that 29 of individuals who

walk to and from public transit achieve at least

30 minutes of daily physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Zone for mixed-use development

--Allows residential commercial institutional amp

other public land uses to be located in close

proximity to one another

--Studies using correlation analyses amp regression

models indicated that mixed land use was

associated with increased walking amp cycling

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance personal safety in areas where

persons are or could be physically active

--Cross-sectional studies have demonstrated a

negative relationship between crime rates andor

perceived safety amp physical activity in

neighborhoods

--Few intervention studies have evaluated the

impact of policies amp practices to improve

personal safety on physical activity

Geospatial Mapping Linking Urban

Environments to Health Risk

Measure association between environmental variables amp health risk factors

Assess relationships between variables at different levels of analysis

Used in conjunction with linear analyses

Our Community Environmental Model

of Obesity

Community Factors

Poverty

Crime

Grocery Quality

Restaurants

Parks

Sidewalks

Fast Food Outlets

Recreational

Facilities

Individual Factors

Dietary Intake

Physical Activity

Genetics

Family History

StressCoping

Eating Disorders

Psychological

Problems

Weight

Status

Chosen Neighborhoods

Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped

We then matched census-block groups within the income groups by population density and percentage of minority representation

One matched block group per income level was randomly selected

Prevalence of Obesity in

Block-Groups

0

5

10

15

20

25

30

35

40

45

50

Ag

e-a

dju

sted

Ob

esit

y P

rev

ale

nce

(

)

High-Income Low-Income

Age-standardized to the 1990 US Census

Density of Environmental Factors in the

Community Contributes to a ldquoToxicrdquo

Obesity Environment

0

2

4

6

8

10

12

14

16

18

Fast-food Convenience Store Bars

Den

sity

10

00

perso

ns

High-Income Low-Income

COMMUNITYrsquoS PERCEPTION OF SAFETY

0

5

10

15

20

25

30

35

40

Daytime Nighttime

Perc

en

t (

) F

eeli

ng

So

mew

hat

Safe

or

Un

safe

Low-Income High-Income

Percent Substandard (or worse) Housing

or Ground Conditions

of Residential Properties

0

10

20

30

Structural Grounds

Perc

en

t (

)

Low-Income High-Income

CONCLUSIONS

These data suggest that the higher

frequency of outlets providing

calorically-dense foods and alcohol may

contribute to greater obesity prevalence

in residents of low-income communities

More research is needed to thoroughly

document environmental determinants

of health and obesity

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

From 1994-1998 HUD randomly assigned

4498 women with children living in public

housing in high-poverty urban census

tracts to one of three groups (1) housing

vouchers redeemable only if they moved

to a low-poverty census tract (2)

unrestricted vouchers or (3) control group

(no vouchers)

Ludwig et al NEJM 201136516

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

10-12 year follow-up showed modest but

potentially important reductions in the

prevalence of extreme obesity amp diabetes in the

group moving from a neighborhood with high

poverty on one of low poverty compared to the

control group

No differences between the group receiving

traditional vouchers amp the control group

ldquoNeighborhoods matterrdquo

Ludwig et al NEJM 201136516

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance traffic safety in areas where

persons are or could be physically active

--Community-scale urban design amp land use policies to

promote physical activity including design components

to improve street lighting infrastructure projects to

increase safety of pedestrian street crossing and use of

traffic calming approaches such as speed humps amp

traffic circles are effective in increasing physical activity

--Both community-scale amp street-scale policies amp practices

are effective in increasing physical activity

Recommended Community Strategies Encourage Communities to Organize for Change

Participate in community coalitions or

partnerships to address obesity

--Little evidence is available to determine the

impact of community coalitions on obesity

prevention

--The presence of anti-smoking community

coalitions has been associated with lower rates

of tobacco consumption

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

$103 million awarded to 61 states and

communities including state amp local government

agencies tribes amp territories amp state amp local non-

profit organizations

To build capacity to implement changes for

community prevention efforts to ensure long-

term success

To implement evidence-based and practice-

based programs to improve health amp wellness

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Priority areas are

Tobacco-free living

Active living and healthy eating

Evidence-based quality clinical and other

preventive health services for prevention

and control of high blood pressure and

high cholesterol

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Applicants proposed specific activities in

line with their chosen priority areas in their

applications

Grantee activities will not be finalized until

plans are negotiated with CDC by early

2012

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Capacity-Building Award

The Confederated Tribes of The Chehalis

Reservation is receiving a $498663 planning

award to build capacity to support healthy

lifestyles among their tribal population of 1500

in Washington State

Work will target tobacco-free living active living

and healthy eating and quality clinical and other

healthy serviceswwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Implementation Award

Austin TX Dept of Health and Human Services

is receiving $1026158 to serve Travis County

(Austin) to expand efforts in tobacco-free living

active living and healthy eating quality clinical

and other preventive services social and

emotional wellness and healthy and safe

physical environmentswwwcdcgov1052011

Building sustainable healthy

communities Bottom line

Obesity is an environmental problem

Despite progress in genetic research public health advances only will occur when we take the environment seriously

Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment

Until we do this we will not make substantial progress in addressing the epidemic of obesity

Poston amp Foreyt Atherosclerosis 1999

Whatrsquos the best approach

Integrate all sectors of society into community

change interventions

Incorporate

Science amp Technology

Education

FamilyCommunity

Healthcare

Arts amp Entertainment

Law amp Politics

Commerce amp Trade

Sectors of Society

Arts amp Entertainm

ent

Commerce amp Trade

Education

FamilyCommunity

Healthcare

Law amp Politics

Science amp Technology

Project FIT rationale design and baseline characteristics of a school- and community-

based intervention to address physical activity and healthy eating among low-income

elementary school children

Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D

Oh HJ Orth J Randall S Mayfield K Holmes D

Source

Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu

Abstract

BACKGROUND

This paper describes Project FIT a collaboration between the public school system local

health systems physicians neighborhood associations businesses faith-based leaders

community agencies and university researchers to develop a multi-faceted approach to

promote physical activity and healthy eating toward the general goal of preventing and

reducing childhood obesity among children in Grand Rapids MI USA

METHODSDESIGN

There are four overall components to Project FIT school community social marketing and

school staff wellness - all that focus on 1) increasing access to safe and affordable physical

activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)

improving the affordability and availability of nutritious food in the neighborhoods surrounding

the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding

nutrition and physical activity among school staff parents and students 4) impacting the

culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging

dialogue among all community partners to leverage existing programs and introduce new

ones

AVERAGE ADULT AMERICAN MAN

Height 5rsquo 8rdquo

Weight 195 lbs

Waist 397 in

BMI 284

CDC 2011

AVERAGE ADULT AMERICAN WOMAN

Height 5rsquo3rdquo

Weight 165 lbs

Waist 370 in

BMI 261

CDC 2011

Miss America

2008

Kirsten Haglund

BMI 1629

Eliana Ramos

Age 18

Height 5rsquo9rdquo

29th OLYMPIAD

BEIJING CHINA

US wrestling team captain Daniel

Cormier (2115 lbs) hospitalized for

kidney failure as result of

dehydration related to cutting weight

(did not compete)

US boxer Gary Russell was found

unconscious 4 days before his

Olympic bout due to cutting weight

(did not compete)

29th OLYMPIAD

BEIJING CHINA

Michael Phelps

8 Gold Medals SwimmingAge 23

Height 6rsquo4rdquo

Weight 195 lbs

BMI 2374

Daily Food Intake 10375 KCAL

(15 PRO 58 CHO 27 FAT)

Exercise 30 hrswk

2005 USDA FOOD PYRAMID

ldquoThe food pyramid

is too complicated

and has too many

messagesrdquo

Robert Post PhD USDA Deputy

Director 2011

2005 USDA FOOD PYRAMID

ldquoItrsquos going to be hard not to do

better than the current pyramid

which basically conveys no

useful informationrdquo

Walter C Willett MD

Chairman Department of Nutrition

Harvard School of Public Health

2011 USDA MY PLATE

ldquoWe are all

bombarded with so

many dietary

messages that it is

hard to find time to

sort through all this

informationrdquo

Michelle Obama 2011

Dietary Guidelines for Americans

2010 Two Primary Concepts

Maintain calorie balance over time to

achieve and maintain a healthy weight

Focus on consuming nutrient-dense foods

and beverages

Dietary Guidelines for Americans 2010

Efficacy-based comparative dietary guidelines

Carb Fat Pro

Mediterranean Diet 45-55 25-35 20

IOM Dietary Ref Intakes 45-65 25-35 15

NCEP-ATPIII 50-60 25-35 15

Am Dietetic Assoc 45-65 20-35 15

PARADOX OF INCREASING OBESITY

PREVALENCE

bull Focus on healthy eating and physical

activity

bull Awareness of dangers of obesity buthellip

bull Obesity prevalence continues to rise

bull Work amp commuting demands

bull Little time to exercise

bull Little time to prepare food

bull Availability of high-fatcalorie foods

Rationale for community-based interventions

bull Increases in obesity prevalence due to genes

bull Increased calories (eg 200 Kcalday

over 10 years)

bull Increased portion sizes (eg 22 oz

steaks and 44 oz sodas)

bull Western diets in developing nations

increase risk of obesity

READINESS TO CHANGE

ldquoHabit is habit and not to be

flung out of the window but

coaxed downstairs a step at a

timerdquo

Mark Twain

Long-Term Weight Maintenance

National Weight Control Registry (N=10000)

Survey of 3000 members who have been in the

Registry for at least 10 years

Starting weight = 224 lbs Average weight loss=69

lbs

At 5 years participants had maintained an average

weight loss=52 lbs

At 10 years participants had maintained an average

weight loss=51 lbs

Thomas Bond Phelan et al TOS 2011

Long-Term Weight Maintenance

Weight Maintainers report that they usually

Track their food intake

Count calories or fat grams

Follow a low-calorie low fat diet (1800 caloriesday

less than 30 of calories from fat

Eat breakfast regularly

Limit the amount they eat out (about 3 timesweek

eat fast food less than onceweek)

Thomas Bond Phelan et al TOS 2011

Long-Term Weight Maintenance

Weight Maintainers report that they usually

Eat similar food regularly

Donrsquot splurge much on holidays amp special occasions

Walk about one hourday

Watch less than 10 hours of TV a week

Weigh themselves at least once a week

Thomas Bond Phelan et al TOS 2011

LONG-TERM WEIGHT MAINTENANCE

Continued consumption of a low-

calorie diet with moderate fat intake

Limited fast food

High levels of physical activity

Phalen et al Obesity 2006 14 710-716

LONG-TERM WEIGHT MAINTENANCE

Daily weighing improved

maintenance of weight loss

particularly when delivered

face to face

Wing et al NEJM 2006 3551563-1571

Most Promising Strategies For

Preventing Weight Regain

Providing multi-component

programs with ongoing

professional contacts

Physical activityexercise

Portion controlmeal replacements

Extending treatment through

weekly or bi-weekly sessions

Pharmacotherapy

Perri Foreyt amp Anton Preventing Weight Regain After Weight Loss 2008

Most Promising Strategies For

Preventing Weight Regain

Extended treatments have shown

promise in promoting adherence to

the behaviors required for the long-

term maintenance of weight loss

Continuous care approach focused

on reasonable long-term objectives

appears appropriate for most

patients

Perri Foreyt amp Anton Preventing Weight Regain After Weight

Loss 2008

An Example of a successful long-term

intervention

The Look AHEAD Study

Does Weight Loss Reduce

Cardiovascular Disease and Death in

Overweight Individuals with Diabetes

bull Action for HEAlth in Diabetes

bull Objective to examine in overweight

persons with Type 2 Diabetes the long-

term effects of an intensive lifestyle

intervention program compared to

diabetes education and support

bull 16 Centers

bull 5145 overweight volunteers with

diabetes

Look AHEAD

Look AHEAD

Primary End Point Composite

bull Cardiovascular death (including fatal

myocardial infarction and stroke)

bull Non-fatal myocardial infarction

bull Non-fatal stroke

Winston-Salem

Baltimore

Philadelphia

New York

Providence

Boston

Clinical Site Coordinating Center

Clinical Sites

Seattle

Los Angeles

San AntonioHouston

Baton Rouge

Minneapolis

Memphis

Birmingham

Pittsburgh

Denver

Phoenix

Look AHEADParticipants

101100Baseline weight (kg)

589586Age (years)

9496Attended 1 year exam

360359Baseline BMI

1514Insulin Users

3737Minority

6059Women

(N=2574)(N=2630)

DSELifestyle

p lt 0004

Look AHEAD

Study Interventions

bull Diabetes support and education - DSE (control group)

bull Lifestyle intervention ndash ILI (treatment group)

Look AHEAD

Lifestyle Intervention

Goals

bull 7 weight loss for the group (10

for individual)

bull 175 minutes of moderate intensity

activity

Look AHEAD

Lifestyle Intervention

bull Diet

ndash ADA NCEP (lt 30 fat lt 10 sat fat

gt15 protein)

ndash 1200-1500 (if weight lt250lbs)

ndash 1500-1800 (if weight gt250lbs)

ndash During first 4 weeks to 4 months portion

control (liquid meal replacements or

structured meal plan)

Look AHEAD

Lifestyle Intervention

bull Physical Activity

ndash unsupervised

ndash 175 minutes moderate intensityweek

ndash 5 daysweek

ndash walking

Weight Loss at 1-Year

-9

ILI 0

-1

-2

-3

-4

-5

-6

-7

-8

DSE

p lt 00001

W

eig

ht

Chan

ge

86

07

The Look AHEAD Research Group Diabetes Care 2007

Reduction in Initial Weight by Gender

N=872

N=1229N=1197

N=830

-12

-10

-8

-6

-4

-2

0

0 2 4 6 8 10 12

Months

R

ed

uctio

n in

In

itia

l W

eig

ht

Men

Women

Plt0001

The Look AHEAD Research Group Diabetes Care 2007

Fitness Change () at 1-Year

0

5

10

15

20

25

Mean

Fitness C

hange

Unadjusted

Plt0001Adjusted for 1 Year

Weight Change Plt0001

58

209

108

159

DSE ILI ILIDSE

The Look AHEAD Research Group Diabetes Care 2007

1-Year Changes in Markers of

Diabetes Control

Markers of Diabetes

Control ILI DSE P-value

Hemoglobin A1c () BL

Hemoglobin A1c () Y1

Y1 ndash Baseline

725

661

-064

729

715

-014

026

lt0001

lt0001

Fasting glucose (mgdl) BL

Fasting glucose (mgdl) Y1

Y1 ndash Baseline

1519

1304

-215

1536

1464

-72

021

lt0001

lt0001

Diabetes medications BL

Diabetes medications Y1

Y1 ndash Baseline

865

786

-78

865

887

22

093

lt0001

lt0001

1-Year Changes in Markers of

Blood Pressure ControlMarkers of Blood Pressure

Control ILI DSE P-value

Systolic BP (mmHg) BL

Systolic BP (mmHg) Y1

Y1 ndash Baseline

1282

1214

-68

1294

1266

-28

026

lt0001

lt0001

Diastolic BP (mmHg) BL

Diastolic BP (mmHg) Y1

Y1 ndash Baseline

699

670

-30

704

686

-18

011

lt0001

lt0001

Antihypertensive medications BL

Antihypertensive medications Y1

Y1 ndash Baseline

753

752

-01

737

759

22

023

054

002

1-Year Changes in Markers of Lipid

Control

Markers of Lipid Control ILI DSE P-value

LDL-cholesterol (mgdl) BL

LDL-cholesterol (mgdl) Y1

Y1 ndash Baseline

1122

1070

-52

1124

1067

-57

078

074

049

HDL-cholesterol (mgdl) BL

HDL-cholesterol (mgdl) Y1

Y1 ndash Baseline

435

469

34

436

449

14

080

lt0001

lt0001

Triglycerides (mgdl) BL

Triglycerides (mgdl) Y1

Y1 ndash Baseline

1828

1525

-303

1800

1654

-146

038

lt0001

lt0001

Lipid lowering medications BL

Lipid lowering medications Y1

Y1 ndash Baseline

494

530

37

484

578

94

052

lt0001

lt0001

1-Year Changes in Percent of Participants

Meeting ADA Goals

ADA Goal ILI DSE P-value

Hemoglobin A1c lt 7 BL

Hemoglobin A1c lt 7 Y1

Y1 ndash Baseline

463

727

264

454

508

54

050

lt0001

lt0001

Blood pressure lt 13080 mmHg BL

Blood pressure lt 13080 mmHg Y1

Y1 ndash Baseline

535

686

151

499

570

70

001

lt0001

lt0001

LDL-cholesterol lt 100 mgdl BL

LDL-cholesterol lt 100 mgdl Y1

Y1 ndash Baseline

371

438

67

369

449

80

087

045

034

All three goals BL

All three goals Y1

Y1 ndash Baseline

108

236

128

95

160

65

013

lt0001

lt0001

Mean Changes in Weight Fitness amp BP

Averaged Over Four Years

DSE

Mean

ILI

Mean

P-value

Weight Loss

( initial wt)

-088 -615 lt 00001

Fitness

( METS)

196 1274 lt00001

HbA1c -009 -036 lt 00001

SBP (mm Hg) -297 -533 lt 00001

DBP (mm Hg) -248 -292 0012

Look AHEAD Research Group Arch Int Med 2010

Mean Changes in Lipid Profile

Averaged Over Four Years

DSE

Mean

ILI

Mean

P-value

HDL (mgdl) 197 367 lt00001

TG (mgdl) -1975 -2556 00006

LDL (mgdl) -1284 -1127 0009

LDL (mgdl)

(Adjusting for

medication use)

-922 -875 042

Look AHEAD Research Group Arch Int Med 2010

Percent () Completing Outcome

Measures at Years 1-4

Intervention Group

(ILI)

Year 1 971

Year 2 949

Year 3 940

Year 4 941

Comparison Group

(DSE)

Year 1 957

Year 2 935

Year 3 938

Year 4 931

Look AHEAD Summary

ILI had significantly greater improvements than DSE in all CVD risk factors averaged across 4 years (except LDL-C)

There may be long-term beneficial effects from this 4-year period in which ILI subjects have been exposed to lower CVD risk factors

Longer follow-ups will determine whether these lowered CVD risk factors can be maintained amp whether lifestyle intervention has positive effects on CVD morbidity amp mortality

Mary J

Female

White

56 years old at start of Look AHEAD

study

Past Medical History Type 2 diabetes

overweight diverticulosis arthritis

sleep apnea back pain

Mary J

bullLong term strugglesbull Helping youngest daughter with

personal issues and children

bull Rotator cuff problems

bull Degenerative disks in back

bull Rheumatoid arthritis

bull Diabetes

bull Physically demanding job

bull Financial struggles

Pounds

Years

82007 grandkids enter pre-school

Catherine L

Female

White

47 years old at start of Look AHEAD

study

Past Medical History Type 2 diabetes

overweight high blood pressure

hypothyroidism back pain

Catherine L

Long term struggles

bull Motherrsquos declining health and death

bull Multiple serious injuries

bull Sudden death of sister

bull Death of step-father

bull Declining economy

bull Children living at home

Pounds

Years

Realistic Management Goals

5-10 weight loss

Health energy and fitness

Well-being and self-esteem

Mood and appearance

Functional and recreational

activity

Key Elements

Focus on health and energy

Food and physical activity diaries

Gradual increase in physical activity

Gradual reduction in dietary fat

No feelings of food deprivation

Social support groups

Recommended Strategies for Building

Sustainable Healthy Communities

Overview from USA

Promote the availability of affordable healthy

food and beverages

Support healthy food and beverage choices

Encourage breastfeeding

Encourage physical activity or limit sedentary

activity among children amp youth

Create safe communities that support physical

activity

Encourage communities to organize for change

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Increase the availability of healthier food and

beverage choices in public service venues (eg

schools city amp county buildings etc)

--Insufficient evidence in school-based programs

--Associations suggest availability amp increased

consumption

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve availability of affordable healthier

food amp beverage choices in public service

venues

--Reducing the cost of healthier foods

increases their purchase

--Providing coupons redeemable for

healthier foods increases their purchase

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve geographic availability of

supermarkets in underserved areas

-- Greater access to nearby supermarkets is

associated with healthier eating behaviors

-- Increasing the number of supermarkets in

underserved neighborhoods increased

real estate values increased economic

activity amp employment amp resulted in lower

food prices

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Provide incentives to food retailers to locate in

andor offer healthier food choices in

underserved areas

-- Presence of retail venues that provide healthier

foods is associated with better nutrition

-- Greater availability of supermarkets was

associated with lower adolescent BMI scores

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Improve availability of mechanisms for

purchasing foods from farms

--Evidence supporting a direct link between

purchasing food from farms amp improved diet is

limited

--Two studies of initiatives to encourage

participation in farmersrsquo market showed

increased intention to eat more fruits amp

vegetables but no direct evidence

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Provide incentives for the production

distribution and procurement of foods from local

farms

--No evidence has been published to link local

food production amp health outcomes

--There is a current study exploring the potential

nutritional amp health benefits of eating locally

grown foods

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Restrict availability of less healthy foods amp

beverages in public service venues

--No peer-reviewed studies examined the impact

designed to restrict availability of less healthy

foods in public service venues

--21 states have policies that restrict the sale of

competitive foods in schools beyond USDA

regulations however no studies have evaluated

the impact of the policies

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Institute smaller portion size options in public

service venues

--Evidence is lacking to demonstrate effectiveness

of population-based interventions aimed at

reducing portion sizes in public service venues

--Evidence from clinical studies in laboratories

demonstrates decreasing portion sizes

decreases energy intake

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Limit advertisements of less healthy foods amp

beverages

--Little evidence is available regarding the impact

of restricting advertising on purchasing amp

consumption of less healthy foods

--Cross-sectional time-series studies of tobacco-

control efforts suggest an association between

advertising bans amp decreased tobacco

consumption

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Discourage consumption of sugar-sweetened

beverages

--One longitudinal study of a school-based

intervention among Native-American high school

students showed a substantial reduction in

sugar-sweetened beverages over a 3-year

period

--A RCT of a home-based intervention that

eliminated sugar-sweetened beverages showed

reduction in BMI scores

Recommended Community Strategies Strategies to encourage breastfeeding

Increase support for breastfeeding

--Evidence directly linking environmental

interventions that support breastfeeding with

obesity-related outcomes is lacking

--Epidemiologic studies indicate that breastfeeding

helps prevent pediatric obesity

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Require physical education in schools

--14 studies have demonstrated that school-based

PE was effective in increasing levels of physical

activity and improving physical fitness

--Minimum of 150 minwk in elementary schools

225 minwk in middle schools and high schools

throughout the school year as recommended by

NASPE

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Increase opportunities for extracurricular

physical activity

--Participation in after-school programs increased

studentsrsquo level of physical activity amp improved

obesity-related outcomes (improved CV fitness

reduced body fat)

--2 pilot studies providing extracurricular physical

activity showed increased levels of PA amp

decreased sedentary behavior

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Reduce screen time in public service venues

--A school-based RCT indicated that children who

reduced their television videotape amp video

game use had significant decrease in BMI tricep

skin fold thickness amp waist circumference

compared to controls

--Spending less time watching television is

associated with increased physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Improve access to outdoor recreational

facilities

--Review of 108 studies indicated that access to facilities

and programs for recreation near their homes amp time

spent outdoors correlated positively with increased

physical activity among childrenamp adults

--Perceptions that footpaths are safe for walking was

significantly associated with adults being classified as

physically active at a level sufficient for health benefits

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting

bicycling

--Longitudinal intervention studies have

demonstrated that improving bicycling

infrastructure is associated with increased

frequency of bicycling

--Cross-sectional studies indicated a significant

association between bicycling infrastructure amp

frequency of biking

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting walking

--Reviews of cross-sectional studies of

environmental correlates of physical activity amp

walking generally find a positive association

between infrastructure supportive of walking amp

physical activity

--Identifying amp creating safe routes to school

together with educational components

increased the number of students walking to

school

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Locating schools within easy walking

distance of residential areas

--Community-scale urban design amp land use policies amp

practices including locating schools stores workplaces

amp recreation areas close to residential areas are

effective in facilitating an increase in levels of physical

activity

--Majority of efforts to encourage walking to school involve

improving the routes rather than improving the location

of schools

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Improve access to public transportation

--Insufficient evidence exists to determine

effectiveness of transportation policies in

increasing the level of physical activity or

improving fitness

--1 study indicated that 29 of individuals who

walk to and from public transit achieve at least

30 minutes of daily physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Zone for mixed-use development

--Allows residential commercial institutional amp

other public land uses to be located in close

proximity to one another

--Studies using correlation analyses amp regression

models indicated that mixed land use was

associated with increased walking amp cycling

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance personal safety in areas where

persons are or could be physically active

--Cross-sectional studies have demonstrated a

negative relationship between crime rates andor

perceived safety amp physical activity in

neighborhoods

--Few intervention studies have evaluated the

impact of policies amp practices to improve

personal safety on physical activity

Geospatial Mapping Linking Urban

Environments to Health Risk

Measure association between environmental variables amp health risk factors

Assess relationships between variables at different levels of analysis

Used in conjunction with linear analyses

Our Community Environmental Model

of Obesity

Community Factors

Poverty

Crime

Grocery Quality

Restaurants

Parks

Sidewalks

Fast Food Outlets

Recreational

Facilities

Individual Factors

Dietary Intake

Physical Activity

Genetics

Family History

StressCoping

Eating Disorders

Psychological

Problems

Weight

Status

Chosen Neighborhoods

Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped

We then matched census-block groups within the income groups by population density and percentage of minority representation

One matched block group per income level was randomly selected

Prevalence of Obesity in

Block-Groups

0

5

10

15

20

25

30

35

40

45

50

Ag

e-a

dju

sted

Ob

esit

y P

rev

ale

nce

(

)

High-Income Low-Income

Age-standardized to the 1990 US Census

Density of Environmental Factors in the

Community Contributes to a ldquoToxicrdquo

Obesity Environment

0

2

4

6

8

10

12

14

16

18

Fast-food Convenience Store Bars

Den

sity

10

00

perso

ns

High-Income Low-Income

COMMUNITYrsquoS PERCEPTION OF SAFETY

0

5

10

15

20

25

30

35

40

Daytime Nighttime

Perc

en

t (

) F

eeli

ng

So

mew

hat

Safe

or

Un

safe

Low-Income High-Income

Percent Substandard (or worse) Housing

or Ground Conditions

of Residential Properties

0

10

20

30

Structural Grounds

Perc

en

t (

)

Low-Income High-Income

CONCLUSIONS

These data suggest that the higher

frequency of outlets providing

calorically-dense foods and alcohol may

contribute to greater obesity prevalence

in residents of low-income communities

More research is needed to thoroughly

document environmental determinants

of health and obesity

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

From 1994-1998 HUD randomly assigned

4498 women with children living in public

housing in high-poverty urban census

tracts to one of three groups (1) housing

vouchers redeemable only if they moved

to a low-poverty census tract (2)

unrestricted vouchers or (3) control group

(no vouchers)

Ludwig et al NEJM 201136516

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

10-12 year follow-up showed modest but

potentially important reductions in the

prevalence of extreme obesity amp diabetes in the

group moving from a neighborhood with high

poverty on one of low poverty compared to the

control group

No differences between the group receiving

traditional vouchers amp the control group

ldquoNeighborhoods matterrdquo

Ludwig et al NEJM 201136516

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance traffic safety in areas where

persons are or could be physically active

--Community-scale urban design amp land use policies to

promote physical activity including design components

to improve street lighting infrastructure projects to

increase safety of pedestrian street crossing and use of

traffic calming approaches such as speed humps amp

traffic circles are effective in increasing physical activity

--Both community-scale amp street-scale policies amp practices

are effective in increasing physical activity

Recommended Community Strategies Encourage Communities to Organize for Change

Participate in community coalitions or

partnerships to address obesity

--Little evidence is available to determine the

impact of community coalitions on obesity

prevention

--The presence of anti-smoking community

coalitions has been associated with lower rates

of tobacco consumption

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

$103 million awarded to 61 states and

communities including state amp local government

agencies tribes amp territories amp state amp local non-

profit organizations

To build capacity to implement changes for

community prevention efforts to ensure long-

term success

To implement evidence-based and practice-

based programs to improve health amp wellness

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Priority areas are

Tobacco-free living

Active living and healthy eating

Evidence-based quality clinical and other

preventive health services for prevention

and control of high blood pressure and

high cholesterol

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Applicants proposed specific activities in

line with their chosen priority areas in their

applications

Grantee activities will not be finalized until

plans are negotiated with CDC by early

2012

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Capacity-Building Award

The Confederated Tribes of The Chehalis

Reservation is receiving a $498663 planning

award to build capacity to support healthy

lifestyles among their tribal population of 1500

in Washington State

Work will target tobacco-free living active living

and healthy eating and quality clinical and other

healthy serviceswwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Implementation Award

Austin TX Dept of Health and Human Services

is receiving $1026158 to serve Travis County

(Austin) to expand efforts in tobacco-free living

active living and healthy eating quality clinical

and other preventive services social and

emotional wellness and healthy and safe

physical environmentswwwcdcgov1052011

Building sustainable healthy

communities Bottom line

Obesity is an environmental problem

Despite progress in genetic research public health advances only will occur when we take the environment seriously

Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment

Until we do this we will not make substantial progress in addressing the epidemic of obesity

Poston amp Foreyt Atherosclerosis 1999

Whatrsquos the best approach

Integrate all sectors of society into community

change interventions

Incorporate

Science amp Technology

Education

FamilyCommunity

Healthcare

Arts amp Entertainment

Law amp Politics

Commerce amp Trade

Sectors of Society

Arts amp Entertainm

ent

Commerce amp Trade

Education

FamilyCommunity

Healthcare

Law amp Politics

Science amp Technology

Project FIT rationale design and baseline characteristics of a school- and community-

based intervention to address physical activity and healthy eating among low-income

elementary school children

Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D

Oh HJ Orth J Randall S Mayfield K Holmes D

Source

Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu

Abstract

BACKGROUND

This paper describes Project FIT a collaboration between the public school system local

health systems physicians neighborhood associations businesses faith-based leaders

community agencies and university researchers to develop a multi-faceted approach to

promote physical activity and healthy eating toward the general goal of preventing and

reducing childhood obesity among children in Grand Rapids MI USA

METHODSDESIGN

There are four overall components to Project FIT school community social marketing and

school staff wellness - all that focus on 1) increasing access to safe and affordable physical

activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)

improving the affordability and availability of nutritious food in the neighborhoods surrounding

the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding

nutrition and physical activity among school staff parents and students 4) impacting the

culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging

dialogue among all community partners to leverage existing programs and introduce new

ones

AVERAGE ADULT AMERICAN WOMAN

Height 5rsquo3rdquo

Weight 165 lbs

Waist 370 in

BMI 261

CDC 2011

Miss America

2008

Kirsten Haglund

BMI 1629

Eliana Ramos

Age 18

Height 5rsquo9rdquo

29th OLYMPIAD

BEIJING CHINA

US wrestling team captain Daniel

Cormier (2115 lbs) hospitalized for

kidney failure as result of

dehydration related to cutting weight

(did not compete)

US boxer Gary Russell was found

unconscious 4 days before his

Olympic bout due to cutting weight

(did not compete)

29th OLYMPIAD

BEIJING CHINA

Michael Phelps

8 Gold Medals SwimmingAge 23

Height 6rsquo4rdquo

Weight 195 lbs

BMI 2374

Daily Food Intake 10375 KCAL

(15 PRO 58 CHO 27 FAT)

Exercise 30 hrswk

2005 USDA FOOD PYRAMID

ldquoThe food pyramid

is too complicated

and has too many

messagesrdquo

Robert Post PhD USDA Deputy

Director 2011

2005 USDA FOOD PYRAMID

ldquoItrsquos going to be hard not to do

better than the current pyramid

which basically conveys no

useful informationrdquo

Walter C Willett MD

Chairman Department of Nutrition

Harvard School of Public Health

2011 USDA MY PLATE

ldquoWe are all

bombarded with so

many dietary

messages that it is

hard to find time to

sort through all this

informationrdquo

Michelle Obama 2011

Dietary Guidelines for Americans

2010 Two Primary Concepts

Maintain calorie balance over time to

achieve and maintain a healthy weight

Focus on consuming nutrient-dense foods

and beverages

Dietary Guidelines for Americans 2010

Efficacy-based comparative dietary guidelines

Carb Fat Pro

Mediterranean Diet 45-55 25-35 20

IOM Dietary Ref Intakes 45-65 25-35 15

NCEP-ATPIII 50-60 25-35 15

Am Dietetic Assoc 45-65 20-35 15

PARADOX OF INCREASING OBESITY

PREVALENCE

bull Focus on healthy eating and physical

activity

bull Awareness of dangers of obesity buthellip

bull Obesity prevalence continues to rise

bull Work amp commuting demands

bull Little time to exercise

bull Little time to prepare food

bull Availability of high-fatcalorie foods

Rationale for community-based interventions

bull Increases in obesity prevalence due to genes

bull Increased calories (eg 200 Kcalday

over 10 years)

bull Increased portion sizes (eg 22 oz

steaks and 44 oz sodas)

bull Western diets in developing nations

increase risk of obesity

READINESS TO CHANGE

ldquoHabit is habit and not to be

flung out of the window but

coaxed downstairs a step at a

timerdquo

Mark Twain

Long-Term Weight Maintenance

National Weight Control Registry (N=10000)

Survey of 3000 members who have been in the

Registry for at least 10 years

Starting weight = 224 lbs Average weight loss=69

lbs

At 5 years participants had maintained an average

weight loss=52 lbs

At 10 years participants had maintained an average

weight loss=51 lbs

Thomas Bond Phelan et al TOS 2011

Long-Term Weight Maintenance

Weight Maintainers report that they usually

Track their food intake

Count calories or fat grams

Follow a low-calorie low fat diet (1800 caloriesday

less than 30 of calories from fat

Eat breakfast regularly

Limit the amount they eat out (about 3 timesweek

eat fast food less than onceweek)

Thomas Bond Phelan et al TOS 2011

Long-Term Weight Maintenance

Weight Maintainers report that they usually

Eat similar food regularly

Donrsquot splurge much on holidays amp special occasions

Walk about one hourday

Watch less than 10 hours of TV a week

Weigh themselves at least once a week

Thomas Bond Phelan et al TOS 2011

LONG-TERM WEIGHT MAINTENANCE

Continued consumption of a low-

calorie diet with moderate fat intake

Limited fast food

High levels of physical activity

Phalen et al Obesity 2006 14 710-716

LONG-TERM WEIGHT MAINTENANCE

Daily weighing improved

maintenance of weight loss

particularly when delivered

face to face

Wing et al NEJM 2006 3551563-1571

Most Promising Strategies For

Preventing Weight Regain

Providing multi-component

programs with ongoing

professional contacts

Physical activityexercise

Portion controlmeal replacements

Extending treatment through

weekly or bi-weekly sessions

Pharmacotherapy

Perri Foreyt amp Anton Preventing Weight Regain After Weight Loss 2008

Most Promising Strategies For

Preventing Weight Regain

Extended treatments have shown

promise in promoting adherence to

the behaviors required for the long-

term maintenance of weight loss

Continuous care approach focused

on reasonable long-term objectives

appears appropriate for most

patients

Perri Foreyt amp Anton Preventing Weight Regain After Weight

Loss 2008

An Example of a successful long-term

intervention

The Look AHEAD Study

Does Weight Loss Reduce

Cardiovascular Disease and Death in

Overweight Individuals with Diabetes

bull Action for HEAlth in Diabetes

bull Objective to examine in overweight

persons with Type 2 Diabetes the long-

term effects of an intensive lifestyle

intervention program compared to

diabetes education and support

bull 16 Centers

bull 5145 overweight volunteers with

diabetes

Look AHEAD

Look AHEAD

Primary End Point Composite

bull Cardiovascular death (including fatal

myocardial infarction and stroke)

bull Non-fatal myocardial infarction

bull Non-fatal stroke

Winston-Salem

Baltimore

Philadelphia

New York

Providence

Boston

Clinical Site Coordinating Center

Clinical Sites

Seattle

Los Angeles

San AntonioHouston

Baton Rouge

Minneapolis

Memphis

Birmingham

Pittsburgh

Denver

Phoenix

Look AHEADParticipants

101100Baseline weight (kg)

589586Age (years)

9496Attended 1 year exam

360359Baseline BMI

1514Insulin Users

3737Minority

6059Women

(N=2574)(N=2630)

DSELifestyle

p lt 0004

Look AHEAD

Study Interventions

bull Diabetes support and education - DSE (control group)

bull Lifestyle intervention ndash ILI (treatment group)

Look AHEAD

Lifestyle Intervention

Goals

bull 7 weight loss for the group (10

for individual)

bull 175 minutes of moderate intensity

activity

Look AHEAD

Lifestyle Intervention

bull Diet

ndash ADA NCEP (lt 30 fat lt 10 sat fat

gt15 protein)

ndash 1200-1500 (if weight lt250lbs)

ndash 1500-1800 (if weight gt250lbs)

ndash During first 4 weeks to 4 months portion

control (liquid meal replacements or

structured meal plan)

Look AHEAD

Lifestyle Intervention

bull Physical Activity

ndash unsupervised

ndash 175 minutes moderate intensityweek

ndash 5 daysweek

ndash walking

Weight Loss at 1-Year

-9

ILI 0

-1

-2

-3

-4

-5

-6

-7

-8

DSE

p lt 00001

W

eig

ht

Chan

ge

86

07

The Look AHEAD Research Group Diabetes Care 2007

Reduction in Initial Weight by Gender

N=872

N=1229N=1197

N=830

-12

-10

-8

-6

-4

-2

0

0 2 4 6 8 10 12

Months

R

ed

uctio

n in

In

itia

l W

eig

ht

Men

Women

Plt0001

The Look AHEAD Research Group Diabetes Care 2007

Fitness Change () at 1-Year

0

5

10

15

20

25

Mean

Fitness C

hange

Unadjusted

Plt0001Adjusted for 1 Year

Weight Change Plt0001

58

209

108

159

DSE ILI ILIDSE

The Look AHEAD Research Group Diabetes Care 2007

1-Year Changes in Markers of

Diabetes Control

Markers of Diabetes

Control ILI DSE P-value

Hemoglobin A1c () BL

Hemoglobin A1c () Y1

Y1 ndash Baseline

725

661

-064

729

715

-014

026

lt0001

lt0001

Fasting glucose (mgdl) BL

Fasting glucose (mgdl) Y1

Y1 ndash Baseline

1519

1304

-215

1536

1464

-72

021

lt0001

lt0001

Diabetes medications BL

Diabetes medications Y1

Y1 ndash Baseline

865

786

-78

865

887

22

093

lt0001

lt0001

1-Year Changes in Markers of

Blood Pressure ControlMarkers of Blood Pressure

Control ILI DSE P-value

Systolic BP (mmHg) BL

Systolic BP (mmHg) Y1

Y1 ndash Baseline

1282

1214

-68

1294

1266

-28

026

lt0001

lt0001

Diastolic BP (mmHg) BL

Diastolic BP (mmHg) Y1

Y1 ndash Baseline

699

670

-30

704

686

-18

011

lt0001

lt0001

Antihypertensive medications BL

Antihypertensive medications Y1

Y1 ndash Baseline

753

752

-01

737

759

22

023

054

002

1-Year Changes in Markers of Lipid

Control

Markers of Lipid Control ILI DSE P-value

LDL-cholesterol (mgdl) BL

LDL-cholesterol (mgdl) Y1

Y1 ndash Baseline

1122

1070

-52

1124

1067

-57

078

074

049

HDL-cholesterol (mgdl) BL

HDL-cholesterol (mgdl) Y1

Y1 ndash Baseline

435

469

34

436

449

14

080

lt0001

lt0001

Triglycerides (mgdl) BL

Triglycerides (mgdl) Y1

Y1 ndash Baseline

1828

1525

-303

1800

1654

-146

038

lt0001

lt0001

Lipid lowering medications BL

Lipid lowering medications Y1

Y1 ndash Baseline

494

530

37

484

578

94

052

lt0001

lt0001

1-Year Changes in Percent of Participants

Meeting ADA Goals

ADA Goal ILI DSE P-value

Hemoglobin A1c lt 7 BL

Hemoglobin A1c lt 7 Y1

Y1 ndash Baseline

463

727

264

454

508

54

050

lt0001

lt0001

Blood pressure lt 13080 mmHg BL

Blood pressure lt 13080 mmHg Y1

Y1 ndash Baseline

535

686

151

499

570

70

001

lt0001

lt0001

LDL-cholesterol lt 100 mgdl BL

LDL-cholesterol lt 100 mgdl Y1

Y1 ndash Baseline

371

438

67

369

449

80

087

045

034

All three goals BL

All three goals Y1

Y1 ndash Baseline

108

236

128

95

160

65

013

lt0001

lt0001

Mean Changes in Weight Fitness amp BP

Averaged Over Four Years

DSE

Mean

ILI

Mean

P-value

Weight Loss

( initial wt)

-088 -615 lt 00001

Fitness

( METS)

196 1274 lt00001

HbA1c -009 -036 lt 00001

SBP (mm Hg) -297 -533 lt 00001

DBP (mm Hg) -248 -292 0012

Look AHEAD Research Group Arch Int Med 2010

Mean Changes in Lipid Profile

Averaged Over Four Years

DSE

Mean

ILI

Mean

P-value

HDL (mgdl) 197 367 lt00001

TG (mgdl) -1975 -2556 00006

LDL (mgdl) -1284 -1127 0009

LDL (mgdl)

(Adjusting for

medication use)

-922 -875 042

Look AHEAD Research Group Arch Int Med 2010

Percent () Completing Outcome

Measures at Years 1-4

Intervention Group

(ILI)

Year 1 971

Year 2 949

Year 3 940

Year 4 941

Comparison Group

(DSE)

Year 1 957

Year 2 935

Year 3 938

Year 4 931

Look AHEAD Summary

ILI had significantly greater improvements than DSE in all CVD risk factors averaged across 4 years (except LDL-C)

There may be long-term beneficial effects from this 4-year period in which ILI subjects have been exposed to lower CVD risk factors

Longer follow-ups will determine whether these lowered CVD risk factors can be maintained amp whether lifestyle intervention has positive effects on CVD morbidity amp mortality

Mary J

Female

White

56 years old at start of Look AHEAD

study

Past Medical History Type 2 diabetes

overweight diverticulosis arthritis

sleep apnea back pain

Mary J

bullLong term strugglesbull Helping youngest daughter with

personal issues and children

bull Rotator cuff problems

bull Degenerative disks in back

bull Rheumatoid arthritis

bull Diabetes

bull Physically demanding job

bull Financial struggles

Pounds

Years

82007 grandkids enter pre-school

Catherine L

Female

White

47 years old at start of Look AHEAD

study

Past Medical History Type 2 diabetes

overweight high blood pressure

hypothyroidism back pain

Catherine L

Long term struggles

bull Motherrsquos declining health and death

bull Multiple serious injuries

bull Sudden death of sister

bull Death of step-father

bull Declining economy

bull Children living at home

Pounds

Years

Realistic Management Goals

5-10 weight loss

Health energy and fitness

Well-being and self-esteem

Mood and appearance

Functional and recreational

activity

Key Elements

Focus on health and energy

Food and physical activity diaries

Gradual increase in physical activity

Gradual reduction in dietary fat

No feelings of food deprivation

Social support groups

Recommended Strategies for Building

Sustainable Healthy Communities

Overview from USA

Promote the availability of affordable healthy

food and beverages

Support healthy food and beverage choices

Encourage breastfeeding

Encourage physical activity or limit sedentary

activity among children amp youth

Create safe communities that support physical

activity

Encourage communities to organize for change

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Increase the availability of healthier food and

beverage choices in public service venues (eg

schools city amp county buildings etc)

--Insufficient evidence in school-based programs

--Associations suggest availability amp increased

consumption

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve availability of affordable healthier

food amp beverage choices in public service

venues

--Reducing the cost of healthier foods

increases their purchase

--Providing coupons redeemable for

healthier foods increases their purchase

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve geographic availability of

supermarkets in underserved areas

-- Greater access to nearby supermarkets is

associated with healthier eating behaviors

-- Increasing the number of supermarkets in

underserved neighborhoods increased

real estate values increased economic

activity amp employment amp resulted in lower

food prices

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Provide incentives to food retailers to locate in

andor offer healthier food choices in

underserved areas

-- Presence of retail venues that provide healthier

foods is associated with better nutrition

-- Greater availability of supermarkets was

associated with lower adolescent BMI scores

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Improve availability of mechanisms for

purchasing foods from farms

--Evidence supporting a direct link between

purchasing food from farms amp improved diet is

limited

--Two studies of initiatives to encourage

participation in farmersrsquo market showed

increased intention to eat more fruits amp

vegetables but no direct evidence

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Provide incentives for the production

distribution and procurement of foods from local

farms

--No evidence has been published to link local

food production amp health outcomes

--There is a current study exploring the potential

nutritional amp health benefits of eating locally

grown foods

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Restrict availability of less healthy foods amp

beverages in public service venues

--No peer-reviewed studies examined the impact

designed to restrict availability of less healthy

foods in public service venues

--21 states have policies that restrict the sale of

competitive foods in schools beyond USDA

regulations however no studies have evaluated

the impact of the policies

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Institute smaller portion size options in public

service venues

--Evidence is lacking to demonstrate effectiveness

of population-based interventions aimed at

reducing portion sizes in public service venues

--Evidence from clinical studies in laboratories

demonstrates decreasing portion sizes

decreases energy intake

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Limit advertisements of less healthy foods amp

beverages

--Little evidence is available regarding the impact

of restricting advertising on purchasing amp

consumption of less healthy foods

--Cross-sectional time-series studies of tobacco-

control efforts suggest an association between

advertising bans amp decreased tobacco

consumption

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Discourage consumption of sugar-sweetened

beverages

--One longitudinal study of a school-based

intervention among Native-American high school

students showed a substantial reduction in

sugar-sweetened beverages over a 3-year

period

--A RCT of a home-based intervention that

eliminated sugar-sweetened beverages showed

reduction in BMI scores

Recommended Community Strategies Strategies to encourage breastfeeding

Increase support for breastfeeding

--Evidence directly linking environmental

interventions that support breastfeeding with

obesity-related outcomes is lacking

--Epidemiologic studies indicate that breastfeeding

helps prevent pediatric obesity

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Require physical education in schools

--14 studies have demonstrated that school-based

PE was effective in increasing levels of physical

activity and improving physical fitness

--Minimum of 150 minwk in elementary schools

225 minwk in middle schools and high schools

throughout the school year as recommended by

NASPE

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Increase opportunities for extracurricular

physical activity

--Participation in after-school programs increased

studentsrsquo level of physical activity amp improved

obesity-related outcomes (improved CV fitness

reduced body fat)

--2 pilot studies providing extracurricular physical

activity showed increased levels of PA amp

decreased sedentary behavior

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Reduce screen time in public service venues

--A school-based RCT indicated that children who

reduced their television videotape amp video

game use had significant decrease in BMI tricep

skin fold thickness amp waist circumference

compared to controls

--Spending less time watching television is

associated with increased physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Improve access to outdoor recreational

facilities

--Review of 108 studies indicated that access to facilities

and programs for recreation near their homes amp time

spent outdoors correlated positively with increased

physical activity among childrenamp adults

--Perceptions that footpaths are safe for walking was

significantly associated with adults being classified as

physically active at a level sufficient for health benefits

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting

bicycling

--Longitudinal intervention studies have

demonstrated that improving bicycling

infrastructure is associated with increased

frequency of bicycling

--Cross-sectional studies indicated a significant

association between bicycling infrastructure amp

frequency of biking

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting walking

--Reviews of cross-sectional studies of

environmental correlates of physical activity amp

walking generally find a positive association

between infrastructure supportive of walking amp

physical activity

--Identifying amp creating safe routes to school

together with educational components

increased the number of students walking to

school

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Locating schools within easy walking

distance of residential areas

--Community-scale urban design amp land use policies amp

practices including locating schools stores workplaces

amp recreation areas close to residential areas are

effective in facilitating an increase in levels of physical

activity

--Majority of efforts to encourage walking to school involve

improving the routes rather than improving the location

of schools

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Improve access to public transportation

--Insufficient evidence exists to determine

effectiveness of transportation policies in

increasing the level of physical activity or

improving fitness

--1 study indicated that 29 of individuals who

walk to and from public transit achieve at least

30 minutes of daily physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Zone for mixed-use development

--Allows residential commercial institutional amp

other public land uses to be located in close

proximity to one another

--Studies using correlation analyses amp regression

models indicated that mixed land use was

associated with increased walking amp cycling

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance personal safety in areas where

persons are or could be physically active

--Cross-sectional studies have demonstrated a

negative relationship between crime rates andor

perceived safety amp physical activity in

neighborhoods

--Few intervention studies have evaluated the

impact of policies amp practices to improve

personal safety on physical activity

Geospatial Mapping Linking Urban

Environments to Health Risk

Measure association between environmental variables amp health risk factors

Assess relationships between variables at different levels of analysis

Used in conjunction with linear analyses

Our Community Environmental Model

of Obesity

Community Factors

Poverty

Crime

Grocery Quality

Restaurants

Parks

Sidewalks

Fast Food Outlets

Recreational

Facilities

Individual Factors

Dietary Intake

Physical Activity

Genetics

Family History

StressCoping

Eating Disorders

Psychological

Problems

Weight

Status

Chosen Neighborhoods

Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped

We then matched census-block groups within the income groups by population density and percentage of minority representation

One matched block group per income level was randomly selected

Prevalence of Obesity in

Block-Groups

0

5

10

15

20

25

30

35

40

45

50

Ag

e-a

dju

sted

Ob

esit

y P

rev

ale

nce

(

)

High-Income Low-Income

Age-standardized to the 1990 US Census

Density of Environmental Factors in the

Community Contributes to a ldquoToxicrdquo

Obesity Environment

0

2

4

6

8

10

12

14

16

18

Fast-food Convenience Store Bars

Den

sity

10

00

perso

ns

High-Income Low-Income

COMMUNITYrsquoS PERCEPTION OF SAFETY

0

5

10

15

20

25

30

35

40

Daytime Nighttime

Perc

en

t (

) F

eeli

ng

So

mew

hat

Safe

or

Un

safe

Low-Income High-Income

Percent Substandard (or worse) Housing

or Ground Conditions

of Residential Properties

0

10

20

30

Structural Grounds

Perc

en

t (

)

Low-Income High-Income

CONCLUSIONS

These data suggest that the higher

frequency of outlets providing

calorically-dense foods and alcohol may

contribute to greater obesity prevalence

in residents of low-income communities

More research is needed to thoroughly

document environmental determinants

of health and obesity

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

From 1994-1998 HUD randomly assigned

4498 women with children living in public

housing in high-poverty urban census

tracts to one of three groups (1) housing

vouchers redeemable only if they moved

to a low-poverty census tract (2)

unrestricted vouchers or (3) control group

(no vouchers)

Ludwig et al NEJM 201136516

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

10-12 year follow-up showed modest but

potentially important reductions in the

prevalence of extreme obesity amp diabetes in the

group moving from a neighborhood with high

poverty on one of low poverty compared to the

control group

No differences between the group receiving

traditional vouchers amp the control group

ldquoNeighborhoods matterrdquo

Ludwig et al NEJM 201136516

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance traffic safety in areas where

persons are or could be physically active

--Community-scale urban design amp land use policies to

promote physical activity including design components

to improve street lighting infrastructure projects to

increase safety of pedestrian street crossing and use of

traffic calming approaches such as speed humps amp

traffic circles are effective in increasing physical activity

--Both community-scale amp street-scale policies amp practices

are effective in increasing physical activity

Recommended Community Strategies Encourage Communities to Organize for Change

Participate in community coalitions or

partnerships to address obesity

--Little evidence is available to determine the

impact of community coalitions on obesity

prevention

--The presence of anti-smoking community

coalitions has been associated with lower rates

of tobacco consumption

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

$103 million awarded to 61 states and

communities including state amp local government

agencies tribes amp territories amp state amp local non-

profit organizations

To build capacity to implement changes for

community prevention efforts to ensure long-

term success

To implement evidence-based and practice-

based programs to improve health amp wellness

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Priority areas are

Tobacco-free living

Active living and healthy eating

Evidence-based quality clinical and other

preventive health services for prevention

and control of high blood pressure and

high cholesterol

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Applicants proposed specific activities in

line with their chosen priority areas in their

applications

Grantee activities will not be finalized until

plans are negotiated with CDC by early

2012

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Capacity-Building Award

The Confederated Tribes of The Chehalis

Reservation is receiving a $498663 planning

award to build capacity to support healthy

lifestyles among their tribal population of 1500

in Washington State

Work will target tobacco-free living active living

and healthy eating and quality clinical and other

healthy serviceswwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Implementation Award

Austin TX Dept of Health and Human Services

is receiving $1026158 to serve Travis County

(Austin) to expand efforts in tobacco-free living

active living and healthy eating quality clinical

and other preventive services social and

emotional wellness and healthy and safe

physical environmentswwwcdcgov1052011

Building sustainable healthy

communities Bottom line

Obesity is an environmental problem

Despite progress in genetic research public health advances only will occur when we take the environment seriously

Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment

Until we do this we will not make substantial progress in addressing the epidemic of obesity

Poston amp Foreyt Atherosclerosis 1999

Whatrsquos the best approach

Integrate all sectors of society into community

change interventions

Incorporate

Science amp Technology

Education

FamilyCommunity

Healthcare

Arts amp Entertainment

Law amp Politics

Commerce amp Trade

Sectors of Society

Arts amp Entertainm

ent

Commerce amp Trade

Education

FamilyCommunity

Healthcare

Law amp Politics

Science amp Technology

Project FIT rationale design and baseline characteristics of a school- and community-

based intervention to address physical activity and healthy eating among low-income

elementary school children

Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D

Oh HJ Orth J Randall S Mayfield K Holmes D

Source

Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu

Abstract

BACKGROUND

This paper describes Project FIT a collaboration between the public school system local

health systems physicians neighborhood associations businesses faith-based leaders

community agencies and university researchers to develop a multi-faceted approach to

promote physical activity and healthy eating toward the general goal of preventing and

reducing childhood obesity among children in Grand Rapids MI USA

METHODSDESIGN

There are four overall components to Project FIT school community social marketing and

school staff wellness - all that focus on 1) increasing access to safe and affordable physical

activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)

improving the affordability and availability of nutritious food in the neighborhoods surrounding

the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding

nutrition and physical activity among school staff parents and students 4) impacting the

culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging

dialogue among all community partners to leverage existing programs and introduce new

ones

Miss America

2008

Kirsten Haglund

BMI 1629

Eliana Ramos

Age 18

Height 5rsquo9rdquo

29th OLYMPIAD

BEIJING CHINA

US wrestling team captain Daniel

Cormier (2115 lbs) hospitalized for

kidney failure as result of

dehydration related to cutting weight

(did not compete)

US boxer Gary Russell was found

unconscious 4 days before his

Olympic bout due to cutting weight

(did not compete)

29th OLYMPIAD

BEIJING CHINA

Michael Phelps

8 Gold Medals SwimmingAge 23

Height 6rsquo4rdquo

Weight 195 lbs

BMI 2374

Daily Food Intake 10375 KCAL

(15 PRO 58 CHO 27 FAT)

Exercise 30 hrswk

2005 USDA FOOD PYRAMID

ldquoThe food pyramid

is too complicated

and has too many

messagesrdquo

Robert Post PhD USDA Deputy

Director 2011

2005 USDA FOOD PYRAMID

ldquoItrsquos going to be hard not to do

better than the current pyramid

which basically conveys no

useful informationrdquo

Walter C Willett MD

Chairman Department of Nutrition

Harvard School of Public Health

2011 USDA MY PLATE

ldquoWe are all

bombarded with so

many dietary

messages that it is

hard to find time to

sort through all this

informationrdquo

Michelle Obama 2011

Dietary Guidelines for Americans

2010 Two Primary Concepts

Maintain calorie balance over time to

achieve and maintain a healthy weight

Focus on consuming nutrient-dense foods

and beverages

Dietary Guidelines for Americans 2010

Efficacy-based comparative dietary guidelines

Carb Fat Pro

Mediterranean Diet 45-55 25-35 20

IOM Dietary Ref Intakes 45-65 25-35 15

NCEP-ATPIII 50-60 25-35 15

Am Dietetic Assoc 45-65 20-35 15

PARADOX OF INCREASING OBESITY

PREVALENCE

bull Focus on healthy eating and physical

activity

bull Awareness of dangers of obesity buthellip

bull Obesity prevalence continues to rise

bull Work amp commuting demands

bull Little time to exercise

bull Little time to prepare food

bull Availability of high-fatcalorie foods

Rationale for community-based interventions

bull Increases in obesity prevalence due to genes

bull Increased calories (eg 200 Kcalday

over 10 years)

bull Increased portion sizes (eg 22 oz

steaks and 44 oz sodas)

bull Western diets in developing nations

increase risk of obesity

READINESS TO CHANGE

ldquoHabit is habit and not to be

flung out of the window but

coaxed downstairs a step at a

timerdquo

Mark Twain

Long-Term Weight Maintenance

National Weight Control Registry (N=10000)

Survey of 3000 members who have been in the

Registry for at least 10 years

Starting weight = 224 lbs Average weight loss=69

lbs

At 5 years participants had maintained an average

weight loss=52 lbs

At 10 years participants had maintained an average

weight loss=51 lbs

Thomas Bond Phelan et al TOS 2011

Long-Term Weight Maintenance

Weight Maintainers report that they usually

Track their food intake

Count calories or fat grams

Follow a low-calorie low fat diet (1800 caloriesday

less than 30 of calories from fat

Eat breakfast regularly

Limit the amount they eat out (about 3 timesweek

eat fast food less than onceweek)

Thomas Bond Phelan et al TOS 2011

Long-Term Weight Maintenance

Weight Maintainers report that they usually

Eat similar food regularly

Donrsquot splurge much on holidays amp special occasions

Walk about one hourday

Watch less than 10 hours of TV a week

Weigh themselves at least once a week

Thomas Bond Phelan et al TOS 2011

LONG-TERM WEIGHT MAINTENANCE

Continued consumption of a low-

calorie diet with moderate fat intake

Limited fast food

High levels of physical activity

Phalen et al Obesity 2006 14 710-716

LONG-TERM WEIGHT MAINTENANCE

Daily weighing improved

maintenance of weight loss

particularly when delivered

face to face

Wing et al NEJM 2006 3551563-1571

Most Promising Strategies For

Preventing Weight Regain

Providing multi-component

programs with ongoing

professional contacts

Physical activityexercise

Portion controlmeal replacements

Extending treatment through

weekly or bi-weekly sessions

Pharmacotherapy

Perri Foreyt amp Anton Preventing Weight Regain After Weight Loss 2008

Most Promising Strategies For

Preventing Weight Regain

Extended treatments have shown

promise in promoting adherence to

the behaviors required for the long-

term maintenance of weight loss

Continuous care approach focused

on reasonable long-term objectives

appears appropriate for most

patients

Perri Foreyt amp Anton Preventing Weight Regain After Weight

Loss 2008

An Example of a successful long-term

intervention

The Look AHEAD Study

Does Weight Loss Reduce

Cardiovascular Disease and Death in

Overweight Individuals with Diabetes

bull Action for HEAlth in Diabetes

bull Objective to examine in overweight

persons with Type 2 Diabetes the long-

term effects of an intensive lifestyle

intervention program compared to

diabetes education and support

bull 16 Centers

bull 5145 overweight volunteers with

diabetes

Look AHEAD

Look AHEAD

Primary End Point Composite

bull Cardiovascular death (including fatal

myocardial infarction and stroke)

bull Non-fatal myocardial infarction

bull Non-fatal stroke

Winston-Salem

Baltimore

Philadelphia

New York

Providence

Boston

Clinical Site Coordinating Center

Clinical Sites

Seattle

Los Angeles

San AntonioHouston

Baton Rouge

Minneapolis

Memphis

Birmingham

Pittsburgh

Denver

Phoenix

Look AHEADParticipants

101100Baseline weight (kg)

589586Age (years)

9496Attended 1 year exam

360359Baseline BMI

1514Insulin Users

3737Minority

6059Women

(N=2574)(N=2630)

DSELifestyle

p lt 0004

Look AHEAD

Study Interventions

bull Diabetes support and education - DSE (control group)

bull Lifestyle intervention ndash ILI (treatment group)

Look AHEAD

Lifestyle Intervention

Goals

bull 7 weight loss for the group (10

for individual)

bull 175 minutes of moderate intensity

activity

Look AHEAD

Lifestyle Intervention

bull Diet

ndash ADA NCEP (lt 30 fat lt 10 sat fat

gt15 protein)

ndash 1200-1500 (if weight lt250lbs)

ndash 1500-1800 (if weight gt250lbs)

ndash During first 4 weeks to 4 months portion

control (liquid meal replacements or

structured meal plan)

Look AHEAD

Lifestyle Intervention

bull Physical Activity

ndash unsupervised

ndash 175 minutes moderate intensityweek

ndash 5 daysweek

ndash walking

Weight Loss at 1-Year

-9

ILI 0

-1

-2

-3

-4

-5

-6

-7

-8

DSE

p lt 00001

W

eig

ht

Chan

ge

86

07

The Look AHEAD Research Group Diabetes Care 2007

Reduction in Initial Weight by Gender

N=872

N=1229N=1197

N=830

-12

-10

-8

-6

-4

-2

0

0 2 4 6 8 10 12

Months

R

ed

uctio

n in

In

itia

l W

eig

ht

Men

Women

Plt0001

The Look AHEAD Research Group Diabetes Care 2007

Fitness Change () at 1-Year

0

5

10

15

20

25

Mean

Fitness C

hange

Unadjusted

Plt0001Adjusted for 1 Year

Weight Change Plt0001

58

209

108

159

DSE ILI ILIDSE

The Look AHEAD Research Group Diabetes Care 2007

1-Year Changes in Markers of

Diabetes Control

Markers of Diabetes

Control ILI DSE P-value

Hemoglobin A1c () BL

Hemoglobin A1c () Y1

Y1 ndash Baseline

725

661

-064

729

715

-014

026

lt0001

lt0001

Fasting glucose (mgdl) BL

Fasting glucose (mgdl) Y1

Y1 ndash Baseline

1519

1304

-215

1536

1464

-72

021

lt0001

lt0001

Diabetes medications BL

Diabetes medications Y1

Y1 ndash Baseline

865

786

-78

865

887

22

093

lt0001

lt0001

1-Year Changes in Markers of

Blood Pressure ControlMarkers of Blood Pressure

Control ILI DSE P-value

Systolic BP (mmHg) BL

Systolic BP (mmHg) Y1

Y1 ndash Baseline

1282

1214

-68

1294

1266

-28

026

lt0001

lt0001

Diastolic BP (mmHg) BL

Diastolic BP (mmHg) Y1

Y1 ndash Baseline

699

670

-30

704

686

-18

011

lt0001

lt0001

Antihypertensive medications BL

Antihypertensive medications Y1

Y1 ndash Baseline

753

752

-01

737

759

22

023

054

002

1-Year Changes in Markers of Lipid

Control

Markers of Lipid Control ILI DSE P-value

LDL-cholesterol (mgdl) BL

LDL-cholesterol (mgdl) Y1

Y1 ndash Baseline

1122

1070

-52

1124

1067

-57

078

074

049

HDL-cholesterol (mgdl) BL

HDL-cholesterol (mgdl) Y1

Y1 ndash Baseline

435

469

34

436

449

14

080

lt0001

lt0001

Triglycerides (mgdl) BL

Triglycerides (mgdl) Y1

Y1 ndash Baseline

1828

1525

-303

1800

1654

-146

038

lt0001

lt0001

Lipid lowering medications BL

Lipid lowering medications Y1

Y1 ndash Baseline

494

530

37

484

578

94

052

lt0001

lt0001

1-Year Changes in Percent of Participants

Meeting ADA Goals

ADA Goal ILI DSE P-value

Hemoglobin A1c lt 7 BL

Hemoglobin A1c lt 7 Y1

Y1 ndash Baseline

463

727

264

454

508

54

050

lt0001

lt0001

Blood pressure lt 13080 mmHg BL

Blood pressure lt 13080 mmHg Y1

Y1 ndash Baseline

535

686

151

499

570

70

001

lt0001

lt0001

LDL-cholesterol lt 100 mgdl BL

LDL-cholesterol lt 100 mgdl Y1

Y1 ndash Baseline

371

438

67

369

449

80

087

045

034

All three goals BL

All three goals Y1

Y1 ndash Baseline

108

236

128

95

160

65

013

lt0001

lt0001

Mean Changes in Weight Fitness amp BP

Averaged Over Four Years

DSE

Mean

ILI

Mean

P-value

Weight Loss

( initial wt)

-088 -615 lt 00001

Fitness

( METS)

196 1274 lt00001

HbA1c -009 -036 lt 00001

SBP (mm Hg) -297 -533 lt 00001

DBP (mm Hg) -248 -292 0012

Look AHEAD Research Group Arch Int Med 2010

Mean Changes in Lipid Profile

Averaged Over Four Years

DSE

Mean

ILI

Mean

P-value

HDL (mgdl) 197 367 lt00001

TG (mgdl) -1975 -2556 00006

LDL (mgdl) -1284 -1127 0009

LDL (mgdl)

(Adjusting for

medication use)

-922 -875 042

Look AHEAD Research Group Arch Int Med 2010

Percent () Completing Outcome

Measures at Years 1-4

Intervention Group

(ILI)

Year 1 971

Year 2 949

Year 3 940

Year 4 941

Comparison Group

(DSE)

Year 1 957

Year 2 935

Year 3 938

Year 4 931

Look AHEAD Summary

ILI had significantly greater improvements than DSE in all CVD risk factors averaged across 4 years (except LDL-C)

There may be long-term beneficial effects from this 4-year period in which ILI subjects have been exposed to lower CVD risk factors

Longer follow-ups will determine whether these lowered CVD risk factors can be maintained amp whether lifestyle intervention has positive effects on CVD morbidity amp mortality

Mary J

Female

White

56 years old at start of Look AHEAD

study

Past Medical History Type 2 diabetes

overweight diverticulosis arthritis

sleep apnea back pain

Mary J

bullLong term strugglesbull Helping youngest daughter with

personal issues and children

bull Rotator cuff problems

bull Degenerative disks in back

bull Rheumatoid arthritis

bull Diabetes

bull Physically demanding job

bull Financial struggles

Pounds

Years

82007 grandkids enter pre-school

Catherine L

Female

White

47 years old at start of Look AHEAD

study

Past Medical History Type 2 diabetes

overweight high blood pressure

hypothyroidism back pain

Catherine L

Long term struggles

bull Motherrsquos declining health and death

bull Multiple serious injuries

bull Sudden death of sister

bull Death of step-father

bull Declining economy

bull Children living at home

Pounds

Years

Realistic Management Goals

5-10 weight loss

Health energy and fitness

Well-being and self-esteem

Mood and appearance

Functional and recreational

activity

Key Elements

Focus on health and energy

Food and physical activity diaries

Gradual increase in physical activity

Gradual reduction in dietary fat

No feelings of food deprivation

Social support groups

Recommended Strategies for Building

Sustainable Healthy Communities

Overview from USA

Promote the availability of affordable healthy

food and beverages

Support healthy food and beverage choices

Encourage breastfeeding

Encourage physical activity or limit sedentary

activity among children amp youth

Create safe communities that support physical

activity

Encourage communities to organize for change

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Increase the availability of healthier food and

beverage choices in public service venues (eg

schools city amp county buildings etc)

--Insufficient evidence in school-based programs

--Associations suggest availability amp increased

consumption

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve availability of affordable healthier

food amp beverage choices in public service

venues

--Reducing the cost of healthier foods

increases their purchase

--Providing coupons redeemable for

healthier foods increases their purchase

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve geographic availability of

supermarkets in underserved areas

-- Greater access to nearby supermarkets is

associated with healthier eating behaviors

-- Increasing the number of supermarkets in

underserved neighborhoods increased

real estate values increased economic

activity amp employment amp resulted in lower

food prices

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Provide incentives to food retailers to locate in

andor offer healthier food choices in

underserved areas

-- Presence of retail venues that provide healthier

foods is associated with better nutrition

-- Greater availability of supermarkets was

associated with lower adolescent BMI scores

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Improve availability of mechanisms for

purchasing foods from farms

--Evidence supporting a direct link between

purchasing food from farms amp improved diet is

limited

--Two studies of initiatives to encourage

participation in farmersrsquo market showed

increased intention to eat more fruits amp

vegetables but no direct evidence

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Provide incentives for the production

distribution and procurement of foods from local

farms

--No evidence has been published to link local

food production amp health outcomes

--There is a current study exploring the potential

nutritional amp health benefits of eating locally

grown foods

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Restrict availability of less healthy foods amp

beverages in public service venues

--No peer-reviewed studies examined the impact

designed to restrict availability of less healthy

foods in public service venues

--21 states have policies that restrict the sale of

competitive foods in schools beyond USDA

regulations however no studies have evaluated

the impact of the policies

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Institute smaller portion size options in public

service venues

--Evidence is lacking to demonstrate effectiveness

of population-based interventions aimed at

reducing portion sizes in public service venues

--Evidence from clinical studies in laboratories

demonstrates decreasing portion sizes

decreases energy intake

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Limit advertisements of less healthy foods amp

beverages

--Little evidence is available regarding the impact

of restricting advertising on purchasing amp

consumption of less healthy foods

--Cross-sectional time-series studies of tobacco-

control efforts suggest an association between

advertising bans amp decreased tobacco

consumption

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Discourage consumption of sugar-sweetened

beverages

--One longitudinal study of a school-based

intervention among Native-American high school

students showed a substantial reduction in

sugar-sweetened beverages over a 3-year

period

--A RCT of a home-based intervention that

eliminated sugar-sweetened beverages showed

reduction in BMI scores

Recommended Community Strategies Strategies to encourage breastfeeding

Increase support for breastfeeding

--Evidence directly linking environmental

interventions that support breastfeeding with

obesity-related outcomes is lacking

--Epidemiologic studies indicate that breastfeeding

helps prevent pediatric obesity

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Require physical education in schools

--14 studies have demonstrated that school-based

PE was effective in increasing levels of physical

activity and improving physical fitness

--Minimum of 150 minwk in elementary schools

225 minwk in middle schools and high schools

throughout the school year as recommended by

NASPE

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Increase opportunities for extracurricular

physical activity

--Participation in after-school programs increased

studentsrsquo level of physical activity amp improved

obesity-related outcomes (improved CV fitness

reduced body fat)

--2 pilot studies providing extracurricular physical

activity showed increased levels of PA amp

decreased sedentary behavior

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Reduce screen time in public service venues

--A school-based RCT indicated that children who

reduced their television videotape amp video

game use had significant decrease in BMI tricep

skin fold thickness amp waist circumference

compared to controls

--Spending less time watching television is

associated with increased physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Improve access to outdoor recreational

facilities

--Review of 108 studies indicated that access to facilities

and programs for recreation near their homes amp time

spent outdoors correlated positively with increased

physical activity among childrenamp adults

--Perceptions that footpaths are safe for walking was

significantly associated with adults being classified as

physically active at a level sufficient for health benefits

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting

bicycling

--Longitudinal intervention studies have

demonstrated that improving bicycling

infrastructure is associated with increased

frequency of bicycling

--Cross-sectional studies indicated a significant

association between bicycling infrastructure amp

frequency of biking

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting walking

--Reviews of cross-sectional studies of

environmental correlates of physical activity amp

walking generally find a positive association

between infrastructure supportive of walking amp

physical activity

--Identifying amp creating safe routes to school

together with educational components

increased the number of students walking to

school

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Locating schools within easy walking

distance of residential areas

--Community-scale urban design amp land use policies amp

practices including locating schools stores workplaces

amp recreation areas close to residential areas are

effective in facilitating an increase in levels of physical

activity

--Majority of efforts to encourage walking to school involve

improving the routes rather than improving the location

of schools

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Improve access to public transportation

--Insufficient evidence exists to determine

effectiveness of transportation policies in

increasing the level of physical activity or

improving fitness

--1 study indicated that 29 of individuals who

walk to and from public transit achieve at least

30 minutes of daily physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Zone for mixed-use development

--Allows residential commercial institutional amp

other public land uses to be located in close

proximity to one another

--Studies using correlation analyses amp regression

models indicated that mixed land use was

associated with increased walking amp cycling

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance personal safety in areas where

persons are or could be physically active

--Cross-sectional studies have demonstrated a

negative relationship between crime rates andor

perceived safety amp physical activity in

neighborhoods

--Few intervention studies have evaluated the

impact of policies amp practices to improve

personal safety on physical activity

Geospatial Mapping Linking Urban

Environments to Health Risk

Measure association between environmental variables amp health risk factors

Assess relationships between variables at different levels of analysis

Used in conjunction with linear analyses

Our Community Environmental Model

of Obesity

Community Factors

Poverty

Crime

Grocery Quality

Restaurants

Parks

Sidewalks

Fast Food Outlets

Recreational

Facilities

Individual Factors

Dietary Intake

Physical Activity

Genetics

Family History

StressCoping

Eating Disorders

Psychological

Problems

Weight

Status

Chosen Neighborhoods

Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped

We then matched census-block groups within the income groups by population density and percentage of minority representation

One matched block group per income level was randomly selected

Prevalence of Obesity in

Block-Groups

0

5

10

15

20

25

30

35

40

45

50

Ag

e-a

dju

sted

Ob

esit

y P

rev

ale

nce

(

)

High-Income Low-Income

Age-standardized to the 1990 US Census

Density of Environmental Factors in the

Community Contributes to a ldquoToxicrdquo

Obesity Environment

0

2

4

6

8

10

12

14

16

18

Fast-food Convenience Store Bars

Den

sity

10

00

perso

ns

High-Income Low-Income

COMMUNITYrsquoS PERCEPTION OF SAFETY

0

5

10

15

20

25

30

35

40

Daytime Nighttime

Perc

en

t (

) F

eeli

ng

So

mew

hat

Safe

or

Un

safe

Low-Income High-Income

Percent Substandard (or worse) Housing

or Ground Conditions

of Residential Properties

0

10

20

30

Structural Grounds

Perc

en

t (

)

Low-Income High-Income

CONCLUSIONS

These data suggest that the higher

frequency of outlets providing

calorically-dense foods and alcohol may

contribute to greater obesity prevalence

in residents of low-income communities

More research is needed to thoroughly

document environmental determinants

of health and obesity

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

From 1994-1998 HUD randomly assigned

4498 women with children living in public

housing in high-poverty urban census

tracts to one of three groups (1) housing

vouchers redeemable only if they moved

to a low-poverty census tract (2)

unrestricted vouchers or (3) control group

(no vouchers)

Ludwig et al NEJM 201136516

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

10-12 year follow-up showed modest but

potentially important reductions in the

prevalence of extreme obesity amp diabetes in the

group moving from a neighborhood with high

poverty on one of low poverty compared to the

control group

No differences between the group receiving

traditional vouchers amp the control group

ldquoNeighborhoods matterrdquo

Ludwig et al NEJM 201136516

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance traffic safety in areas where

persons are or could be physically active

--Community-scale urban design amp land use policies to

promote physical activity including design components

to improve street lighting infrastructure projects to

increase safety of pedestrian street crossing and use of

traffic calming approaches such as speed humps amp

traffic circles are effective in increasing physical activity

--Both community-scale amp street-scale policies amp practices

are effective in increasing physical activity

Recommended Community Strategies Encourage Communities to Organize for Change

Participate in community coalitions or

partnerships to address obesity

--Little evidence is available to determine the

impact of community coalitions on obesity

prevention

--The presence of anti-smoking community

coalitions has been associated with lower rates

of tobacco consumption

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

$103 million awarded to 61 states and

communities including state amp local government

agencies tribes amp territories amp state amp local non-

profit organizations

To build capacity to implement changes for

community prevention efforts to ensure long-

term success

To implement evidence-based and practice-

based programs to improve health amp wellness

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Priority areas are

Tobacco-free living

Active living and healthy eating

Evidence-based quality clinical and other

preventive health services for prevention

and control of high blood pressure and

high cholesterol

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Applicants proposed specific activities in

line with their chosen priority areas in their

applications

Grantee activities will not be finalized until

plans are negotiated with CDC by early

2012

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Capacity-Building Award

The Confederated Tribes of The Chehalis

Reservation is receiving a $498663 planning

award to build capacity to support healthy

lifestyles among their tribal population of 1500

in Washington State

Work will target tobacco-free living active living

and healthy eating and quality clinical and other

healthy serviceswwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Implementation Award

Austin TX Dept of Health and Human Services

is receiving $1026158 to serve Travis County

(Austin) to expand efforts in tobacco-free living

active living and healthy eating quality clinical

and other preventive services social and

emotional wellness and healthy and safe

physical environmentswwwcdcgov1052011

Building sustainable healthy

communities Bottom line

Obesity is an environmental problem

Despite progress in genetic research public health advances only will occur when we take the environment seriously

Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment

Until we do this we will not make substantial progress in addressing the epidemic of obesity

Poston amp Foreyt Atherosclerosis 1999

Whatrsquos the best approach

Integrate all sectors of society into community

change interventions

Incorporate

Science amp Technology

Education

FamilyCommunity

Healthcare

Arts amp Entertainment

Law amp Politics

Commerce amp Trade

Sectors of Society

Arts amp Entertainm

ent

Commerce amp Trade

Education

FamilyCommunity

Healthcare

Law amp Politics

Science amp Technology

Project FIT rationale design and baseline characteristics of a school- and community-

based intervention to address physical activity and healthy eating among low-income

elementary school children

Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D

Oh HJ Orth J Randall S Mayfield K Holmes D

Source

Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu

Abstract

BACKGROUND

This paper describes Project FIT a collaboration between the public school system local

health systems physicians neighborhood associations businesses faith-based leaders

community agencies and university researchers to develop a multi-faceted approach to

promote physical activity and healthy eating toward the general goal of preventing and

reducing childhood obesity among children in Grand Rapids MI USA

METHODSDESIGN

There are four overall components to Project FIT school community social marketing and

school staff wellness - all that focus on 1) increasing access to safe and affordable physical

activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)

improving the affordability and availability of nutritious food in the neighborhoods surrounding

the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding

nutrition and physical activity among school staff parents and students 4) impacting the

culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging

dialogue among all community partners to leverage existing programs and introduce new

ones

Eliana Ramos

Age 18

Height 5rsquo9rdquo

29th OLYMPIAD

BEIJING CHINA

US wrestling team captain Daniel

Cormier (2115 lbs) hospitalized for

kidney failure as result of

dehydration related to cutting weight

(did not compete)

US boxer Gary Russell was found

unconscious 4 days before his

Olympic bout due to cutting weight

(did not compete)

29th OLYMPIAD

BEIJING CHINA

Michael Phelps

8 Gold Medals SwimmingAge 23

Height 6rsquo4rdquo

Weight 195 lbs

BMI 2374

Daily Food Intake 10375 KCAL

(15 PRO 58 CHO 27 FAT)

Exercise 30 hrswk

2005 USDA FOOD PYRAMID

ldquoThe food pyramid

is too complicated

and has too many

messagesrdquo

Robert Post PhD USDA Deputy

Director 2011

2005 USDA FOOD PYRAMID

ldquoItrsquos going to be hard not to do

better than the current pyramid

which basically conveys no

useful informationrdquo

Walter C Willett MD

Chairman Department of Nutrition

Harvard School of Public Health

2011 USDA MY PLATE

ldquoWe are all

bombarded with so

many dietary

messages that it is

hard to find time to

sort through all this

informationrdquo

Michelle Obama 2011

Dietary Guidelines for Americans

2010 Two Primary Concepts

Maintain calorie balance over time to

achieve and maintain a healthy weight

Focus on consuming nutrient-dense foods

and beverages

Dietary Guidelines for Americans 2010

Efficacy-based comparative dietary guidelines

Carb Fat Pro

Mediterranean Diet 45-55 25-35 20

IOM Dietary Ref Intakes 45-65 25-35 15

NCEP-ATPIII 50-60 25-35 15

Am Dietetic Assoc 45-65 20-35 15

PARADOX OF INCREASING OBESITY

PREVALENCE

bull Focus on healthy eating and physical

activity

bull Awareness of dangers of obesity buthellip

bull Obesity prevalence continues to rise

bull Work amp commuting demands

bull Little time to exercise

bull Little time to prepare food

bull Availability of high-fatcalorie foods

Rationale for community-based interventions

bull Increases in obesity prevalence due to genes

bull Increased calories (eg 200 Kcalday

over 10 years)

bull Increased portion sizes (eg 22 oz

steaks and 44 oz sodas)

bull Western diets in developing nations

increase risk of obesity

READINESS TO CHANGE

ldquoHabit is habit and not to be

flung out of the window but

coaxed downstairs a step at a

timerdquo

Mark Twain

Long-Term Weight Maintenance

National Weight Control Registry (N=10000)

Survey of 3000 members who have been in the

Registry for at least 10 years

Starting weight = 224 lbs Average weight loss=69

lbs

At 5 years participants had maintained an average

weight loss=52 lbs

At 10 years participants had maintained an average

weight loss=51 lbs

Thomas Bond Phelan et al TOS 2011

Long-Term Weight Maintenance

Weight Maintainers report that they usually

Track their food intake

Count calories or fat grams

Follow a low-calorie low fat diet (1800 caloriesday

less than 30 of calories from fat

Eat breakfast regularly

Limit the amount they eat out (about 3 timesweek

eat fast food less than onceweek)

Thomas Bond Phelan et al TOS 2011

Long-Term Weight Maintenance

Weight Maintainers report that they usually

Eat similar food regularly

Donrsquot splurge much on holidays amp special occasions

Walk about one hourday

Watch less than 10 hours of TV a week

Weigh themselves at least once a week

Thomas Bond Phelan et al TOS 2011

LONG-TERM WEIGHT MAINTENANCE

Continued consumption of a low-

calorie diet with moderate fat intake

Limited fast food

High levels of physical activity

Phalen et al Obesity 2006 14 710-716

LONG-TERM WEIGHT MAINTENANCE

Daily weighing improved

maintenance of weight loss

particularly when delivered

face to face

Wing et al NEJM 2006 3551563-1571

Most Promising Strategies For

Preventing Weight Regain

Providing multi-component

programs with ongoing

professional contacts

Physical activityexercise

Portion controlmeal replacements

Extending treatment through

weekly or bi-weekly sessions

Pharmacotherapy

Perri Foreyt amp Anton Preventing Weight Regain After Weight Loss 2008

Most Promising Strategies For

Preventing Weight Regain

Extended treatments have shown

promise in promoting adherence to

the behaviors required for the long-

term maintenance of weight loss

Continuous care approach focused

on reasonable long-term objectives

appears appropriate for most

patients

Perri Foreyt amp Anton Preventing Weight Regain After Weight

Loss 2008

An Example of a successful long-term

intervention

The Look AHEAD Study

Does Weight Loss Reduce

Cardiovascular Disease and Death in

Overweight Individuals with Diabetes

bull Action for HEAlth in Diabetes

bull Objective to examine in overweight

persons with Type 2 Diabetes the long-

term effects of an intensive lifestyle

intervention program compared to

diabetes education and support

bull 16 Centers

bull 5145 overweight volunteers with

diabetes

Look AHEAD

Look AHEAD

Primary End Point Composite

bull Cardiovascular death (including fatal

myocardial infarction and stroke)

bull Non-fatal myocardial infarction

bull Non-fatal stroke

Winston-Salem

Baltimore

Philadelphia

New York

Providence

Boston

Clinical Site Coordinating Center

Clinical Sites

Seattle

Los Angeles

San AntonioHouston

Baton Rouge

Minneapolis

Memphis

Birmingham

Pittsburgh

Denver

Phoenix

Look AHEADParticipants

101100Baseline weight (kg)

589586Age (years)

9496Attended 1 year exam

360359Baseline BMI

1514Insulin Users

3737Minority

6059Women

(N=2574)(N=2630)

DSELifestyle

p lt 0004

Look AHEAD

Study Interventions

bull Diabetes support and education - DSE (control group)

bull Lifestyle intervention ndash ILI (treatment group)

Look AHEAD

Lifestyle Intervention

Goals

bull 7 weight loss for the group (10

for individual)

bull 175 minutes of moderate intensity

activity

Look AHEAD

Lifestyle Intervention

bull Diet

ndash ADA NCEP (lt 30 fat lt 10 sat fat

gt15 protein)

ndash 1200-1500 (if weight lt250lbs)

ndash 1500-1800 (if weight gt250lbs)

ndash During first 4 weeks to 4 months portion

control (liquid meal replacements or

structured meal plan)

Look AHEAD

Lifestyle Intervention

bull Physical Activity

ndash unsupervised

ndash 175 minutes moderate intensityweek

ndash 5 daysweek

ndash walking

Weight Loss at 1-Year

-9

ILI 0

-1

-2

-3

-4

-5

-6

-7

-8

DSE

p lt 00001

W

eig

ht

Chan

ge

86

07

The Look AHEAD Research Group Diabetes Care 2007

Reduction in Initial Weight by Gender

N=872

N=1229N=1197

N=830

-12

-10

-8

-6

-4

-2

0

0 2 4 6 8 10 12

Months

R

ed

uctio

n in

In

itia

l W

eig

ht

Men

Women

Plt0001

The Look AHEAD Research Group Diabetes Care 2007

Fitness Change () at 1-Year

0

5

10

15

20

25

Mean

Fitness C

hange

Unadjusted

Plt0001Adjusted for 1 Year

Weight Change Plt0001

58

209

108

159

DSE ILI ILIDSE

The Look AHEAD Research Group Diabetes Care 2007

1-Year Changes in Markers of

Diabetes Control

Markers of Diabetes

Control ILI DSE P-value

Hemoglobin A1c () BL

Hemoglobin A1c () Y1

Y1 ndash Baseline

725

661

-064

729

715

-014

026

lt0001

lt0001

Fasting glucose (mgdl) BL

Fasting glucose (mgdl) Y1

Y1 ndash Baseline

1519

1304

-215

1536

1464

-72

021

lt0001

lt0001

Diabetes medications BL

Diabetes medications Y1

Y1 ndash Baseline

865

786

-78

865

887

22

093

lt0001

lt0001

1-Year Changes in Markers of

Blood Pressure ControlMarkers of Blood Pressure

Control ILI DSE P-value

Systolic BP (mmHg) BL

Systolic BP (mmHg) Y1

Y1 ndash Baseline

1282

1214

-68

1294

1266

-28

026

lt0001

lt0001

Diastolic BP (mmHg) BL

Diastolic BP (mmHg) Y1

Y1 ndash Baseline

699

670

-30

704

686

-18

011

lt0001

lt0001

Antihypertensive medications BL

Antihypertensive medications Y1

Y1 ndash Baseline

753

752

-01

737

759

22

023

054

002

1-Year Changes in Markers of Lipid

Control

Markers of Lipid Control ILI DSE P-value

LDL-cholesterol (mgdl) BL

LDL-cholesterol (mgdl) Y1

Y1 ndash Baseline

1122

1070

-52

1124

1067

-57

078

074

049

HDL-cholesterol (mgdl) BL

HDL-cholesterol (mgdl) Y1

Y1 ndash Baseline

435

469

34

436

449

14

080

lt0001

lt0001

Triglycerides (mgdl) BL

Triglycerides (mgdl) Y1

Y1 ndash Baseline

1828

1525

-303

1800

1654

-146

038

lt0001

lt0001

Lipid lowering medications BL

Lipid lowering medications Y1

Y1 ndash Baseline

494

530

37

484

578

94

052

lt0001

lt0001

1-Year Changes in Percent of Participants

Meeting ADA Goals

ADA Goal ILI DSE P-value

Hemoglobin A1c lt 7 BL

Hemoglobin A1c lt 7 Y1

Y1 ndash Baseline

463

727

264

454

508

54

050

lt0001

lt0001

Blood pressure lt 13080 mmHg BL

Blood pressure lt 13080 mmHg Y1

Y1 ndash Baseline

535

686

151

499

570

70

001

lt0001

lt0001

LDL-cholesterol lt 100 mgdl BL

LDL-cholesterol lt 100 mgdl Y1

Y1 ndash Baseline

371

438

67

369

449

80

087

045

034

All three goals BL

All three goals Y1

Y1 ndash Baseline

108

236

128

95

160

65

013

lt0001

lt0001

Mean Changes in Weight Fitness amp BP

Averaged Over Four Years

DSE

Mean

ILI

Mean

P-value

Weight Loss

( initial wt)

-088 -615 lt 00001

Fitness

( METS)

196 1274 lt00001

HbA1c -009 -036 lt 00001

SBP (mm Hg) -297 -533 lt 00001

DBP (mm Hg) -248 -292 0012

Look AHEAD Research Group Arch Int Med 2010

Mean Changes in Lipid Profile

Averaged Over Four Years

DSE

Mean

ILI

Mean

P-value

HDL (mgdl) 197 367 lt00001

TG (mgdl) -1975 -2556 00006

LDL (mgdl) -1284 -1127 0009

LDL (mgdl)

(Adjusting for

medication use)

-922 -875 042

Look AHEAD Research Group Arch Int Med 2010

Percent () Completing Outcome

Measures at Years 1-4

Intervention Group

(ILI)

Year 1 971

Year 2 949

Year 3 940

Year 4 941

Comparison Group

(DSE)

Year 1 957

Year 2 935

Year 3 938

Year 4 931

Look AHEAD Summary

ILI had significantly greater improvements than DSE in all CVD risk factors averaged across 4 years (except LDL-C)

There may be long-term beneficial effects from this 4-year period in which ILI subjects have been exposed to lower CVD risk factors

Longer follow-ups will determine whether these lowered CVD risk factors can be maintained amp whether lifestyle intervention has positive effects on CVD morbidity amp mortality

Mary J

Female

White

56 years old at start of Look AHEAD

study

Past Medical History Type 2 diabetes

overweight diverticulosis arthritis

sleep apnea back pain

Mary J

bullLong term strugglesbull Helping youngest daughter with

personal issues and children

bull Rotator cuff problems

bull Degenerative disks in back

bull Rheumatoid arthritis

bull Diabetes

bull Physically demanding job

bull Financial struggles

Pounds

Years

82007 grandkids enter pre-school

Catherine L

Female

White

47 years old at start of Look AHEAD

study

Past Medical History Type 2 diabetes

overweight high blood pressure

hypothyroidism back pain

Catherine L

Long term struggles

bull Motherrsquos declining health and death

bull Multiple serious injuries

bull Sudden death of sister

bull Death of step-father

bull Declining economy

bull Children living at home

Pounds

Years

Realistic Management Goals

5-10 weight loss

Health energy and fitness

Well-being and self-esteem

Mood and appearance

Functional and recreational

activity

Key Elements

Focus on health and energy

Food and physical activity diaries

Gradual increase in physical activity

Gradual reduction in dietary fat

No feelings of food deprivation

Social support groups

Recommended Strategies for Building

Sustainable Healthy Communities

Overview from USA

Promote the availability of affordable healthy

food and beverages

Support healthy food and beverage choices

Encourage breastfeeding

Encourage physical activity or limit sedentary

activity among children amp youth

Create safe communities that support physical

activity

Encourage communities to organize for change

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Increase the availability of healthier food and

beverage choices in public service venues (eg

schools city amp county buildings etc)

--Insufficient evidence in school-based programs

--Associations suggest availability amp increased

consumption

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve availability of affordable healthier

food amp beverage choices in public service

venues

--Reducing the cost of healthier foods

increases their purchase

--Providing coupons redeemable for

healthier foods increases their purchase

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve geographic availability of

supermarkets in underserved areas

-- Greater access to nearby supermarkets is

associated with healthier eating behaviors

-- Increasing the number of supermarkets in

underserved neighborhoods increased

real estate values increased economic

activity amp employment amp resulted in lower

food prices

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Provide incentives to food retailers to locate in

andor offer healthier food choices in

underserved areas

-- Presence of retail venues that provide healthier

foods is associated with better nutrition

-- Greater availability of supermarkets was

associated with lower adolescent BMI scores

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Improve availability of mechanisms for

purchasing foods from farms

--Evidence supporting a direct link between

purchasing food from farms amp improved diet is

limited

--Two studies of initiatives to encourage

participation in farmersrsquo market showed

increased intention to eat more fruits amp

vegetables but no direct evidence

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Provide incentives for the production

distribution and procurement of foods from local

farms

--No evidence has been published to link local

food production amp health outcomes

--There is a current study exploring the potential

nutritional amp health benefits of eating locally

grown foods

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Restrict availability of less healthy foods amp

beverages in public service venues

--No peer-reviewed studies examined the impact

designed to restrict availability of less healthy

foods in public service venues

--21 states have policies that restrict the sale of

competitive foods in schools beyond USDA

regulations however no studies have evaluated

the impact of the policies

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Institute smaller portion size options in public

service venues

--Evidence is lacking to demonstrate effectiveness

of population-based interventions aimed at

reducing portion sizes in public service venues

--Evidence from clinical studies in laboratories

demonstrates decreasing portion sizes

decreases energy intake

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Limit advertisements of less healthy foods amp

beverages

--Little evidence is available regarding the impact

of restricting advertising on purchasing amp

consumption of less healthy foods

--Cross-sectional time-series studies of tobacco-

control efforts suggest an association between

advertising bans amp decreased tobacco

consumption

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Discourage consumption of sugar-sweetened

beverages

--One longitudinal study of a school-based

intervention among Native-American high school

students showed a substantial reduction in

sugar-sweetened beverages over a 3-year

period

--A RCT of a home-based intervention that

eliminated sugar-sweetened beverages showed

reduction in BMI scores

Recommended Community Strategies Strategies to encourage breastfeeding

Increase support for breastfeeding

--Evidence directly linking environmental

interventions that support breastfeeding with

obesity-related outcomes is lacking

--Epidemiologic studies indicate that breastfeeding

helps prevent pediatric obesity

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Require physical education in schools

--14 studies have demonstrated that school-based

PE was effective in increasing levels of physical

activity and improving physical fitness

--Minimum of 150 minwk in elementary schools

225 minwk in middle schools and high schools

throughout the school year as recommended by

NASPE

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Increase opportunities for extracurricular

physical activity

--Participation in after-school programs increased

studentsrsquo level of physical activity amp improved

obesity-related outcomes (improved CV fitness

reduced body fat)

--2 pilot studies providing extracurricular physical

activity showed increased levels of PA amp

decreased sedentary behavior

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Reduce screen time in public service venues

--A school-based RCT indicated that children who

reduced their television videotape amp video

game use had significant decrease in BMI tricep

skin fold thickness amp waist circumference

compared to controls

--Spending less time watching television is

associated with increased physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Improve access to outdoor recreational

facilities

--Review of 108 studies indicated that access to facilities

and programs for recreation near their homes amp time

spent outdoors correlated positively with increased

physical activity among childrenamp adults

--Perceptions that footpaths are safe for walking was

significantly associated with adults being classified as

physically active at a level sufficient for health benefits

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting

bicycling

--Longitudinal intervention studies have

demonstrated that improving bicycling

infrastructure is associated with increased

frequency of bicycling

--Cross-sectional studies indicated a significant

association between bicycling infrastructure amp

frequency of biking

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting walking

--Reviews of cross-sectional studies of

environmental correlates of physical activity amp

walking generally find a positive association

between infrastructure supportive of walking amp

physical activity

--Identifying amp creating safe routes to school

together with educational components

increased the number of students walking to

school

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Locating schools within easy walking

distance of residential areas

--Community-scale urban design amp land use policies amp

practices including locating schools stores workplaces

amp recreation areas close to residential areas are

effective in facilitating an increase in levels of physical

activity

--Majority of efforts to encourage walking to school involve

improving the routes rather than improving the location

of schools

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Improve access to public transportation

--Insufficient evidence exists to determine

effectiveness of transportation policies in

increasing the level of physical activity or

improving fitness

--1 study indicated that 29 of individuals who

walk to and from public transit achieve at least

30 minutes of daily physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Zone for mixed-use development

--Allows residential commercial institutional amp

other public land uses to be located in close

proximity to one another

--Studies using correlation analyses amp regression

models indicated that mixed land use was

associated with increased walking amp cycling

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance personal safety in areas where

persons are or could be physically active

--Cross-sectional studies have demonstrated a

negative relationship between crime rates andor

perceived safety amp physical activity in

neighborhoods

--Few intervention studies have evaluated the

impact of policies amp practices to improve

personal safety on physical activity

Geospatial Mapping Linking Urban

Environments to Health Risk

Measure association between environmental variables amp health risk factors

Assess relationships between variables at different levels of analysis

Used in conjunction with linear analyses

Our Community Environmental Model

of Obesity

Community Factors

Poverty

Crime

Grocery Quality

Restaurants

Parks

Sidewalks

Fast Food Outlets

Recreational

Facilities

Individual Factors

Dietary Intake

Physical Activity

Genetics

Family History

StressCoping

Eating Disorders

Psychological

Problems

Weight

Status

Chosen Neighborhoods

Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped

We then matched census-block groups within the income groups by population density and percentage of minority representation

One matched block group per income level was randomly selected

Prevalence of Obesity in

Block-Groups

0

5

10

15

20

25

30

35

40

45

50

Ag

e-a

dju

sted

Ob

esit

y P

rev

ale

nce

(

)

High-Income Low-Income

Age-standardized to the 1990 US Census

Density of Environmental Factors in the

Community Contributes to a ldquoToxicrdquo

Obesity Environment

0

2

4

6

8

10

12

14

16

18

Fast-food Convenience Store Bars

Den

sity

10

00

perso

ns

High-Income Low-Income

COMMUNITYrsquoS PERCEPTION OF SAFETY

0

5

10

15

20

25

30

35

40

Daytime Nighttime

Perc

en

t (

) F

eeli

ng

So

mew

hat

Safe

or

Un

safe

Low-Income High-Income

Percent Substandard (or worse) Housing

or Ground Conditions

of Residential Properties

0

10

20

30

Structural Grounds

Perc

en

t (

)

Low-Income High-Income

CONCLUSIONS

These data suggest that the higher

frequency of outlets providing

calorically-dense foods and alcohol may

contribute to greater obesity prevalence

in residents of low-income communities

More research is needed to thoroughly

document environmental determinants

of health and obesity

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

From 1994-1998 HUD randomly assigned

4498 women with children living in public

housing in high-poverty urban census

tracts to one of three groups (1) housing

vouchers redeemable only if they moved

to a low-poverty census tract (2)

unrestricted vouchers or (3) control group

(no vouchers)

Ludwig et al NEJM 201136516

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

10-12 year follow-up showed modest but

potentially important reductions in the

prevalence of extreme obesity amp diabetes in the

group moving from a neighborhood with high

poverty on one of low poverty compared to the

control group

No differences between the group receiving

traditional vouchers amp the control group

ldquoNeighborhoods matterrdquo

Ludwig et al NEJM 201136516

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance traffic safety in areas where

persons are or could be physically active

--Community-scale urban design amp land use policies to

promote physical activity including design components

to improve street lighting infrastructure projects to

increase safety of pedestrian street crossing and use of

traffic calming approaches such as speed humps amp

traffic circles are effective in increasing physical activity

--Both community-scale amp street-scale policies amp practices

are effective in increasing physical activity

Recommended Community Strategies Encourage Communities to Organize for Change

Participate in community coalitions or

partnerships to address obesity

--Little evidence is available to determine the

impact of community coalitions on obesity

prevention

--The presence of anti-smoking community

coalitions has been associated with lower rates

of tobacco consumption

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

$103 million awarded to 61 states and

communities including state amp local government

agencies tribes amp territories amp state amp local non-

profit organizations

To build capacity to implement changes for

community prevention efforts to ensure long-

term success

To implement evidence-based and practice-

based programs to improve health amp wellness

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Priority areas are

Tobacco-free living

Active living and healthy eating

Evidence-based quality clinical and other

preventive health services for prevention

and control of high blood pressure and

high cholesterol

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Applicants proposed specific activities in

line with their chosen priority areas in their

applications

Grantee activities will not be finalized until

plans are negotiated with CDC by early

2012

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Capacity-Building Award

The Confederated Tribes of The Chehalis

Reservation is receiving a $498663 planning

award to build capacity to support healthy

lifestyles among their tribal population of 1500

in Washington State

Work will target tobacco-free living active living

and healthy eating and quality clinical and other

healthy serviceswwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Implementation Award

Austin TX Dept of Health and Human Services

is receiving $1026158 to serve Travis County

(Austin) to expand efforts in tobacco-free living

active living and healthy eating quality clinical

and other preventive services social and

emotional wellness and healthy and safe

physical environmentswwwcdcgov1052011

Building sustainable healthy

communities Bottom line

Obesity is an environmental problem

Despite progress in genetic research public health advances only will occur when we take the environment seriously

Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment

Until we do this we will not make substantial progress in addressing the epidemic of obesity

Poston amp Foreyt Atherosclerosis 1999

Whatrsquos the best approach

Integrate all sectors of society into community

change interventions

Incorporate

Science amp Technology

Education

FamilyCommunity

Healthcare

Arts amp Entertainment

Law amp Politics

Commerce amp Trade

Sectors of Society

Arts amp Entertainm

ent

Commerce amp Trade

Education

FamilyCommunity

Healthcare

Law amp Politics

Science amp Technology

Project FIT rationale design and baseline characteristics of a school- and community-

based intervention to address physical activity and healthy eating among low-income

elementary school children

Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D

Oh HJ Orth J Randall S Mayfield K Holmes D

Source

Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu

Abstract

BACKGROUND

This paper describes Project FIT a collaboration between the public school system local

health systems physicians neighborhood associations businesses faith-based leaders

community agencies and university researchers to develop a multi-faceted approach to

promote physical activity and healthy eating toward the general goal of preventing and

reducing childhood obesity among children in Grand Rapids MI USA

METHODSDESIGN

There are four overall components to Project FIT school community social marketing and

school staff wellness - all that focus on 1) increasing access to safe and affordable physical

activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)

improving the affordability and availability of nutritious food in the neighborhoods surrounding

the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding

nutrition and physical activity among school staff parents and students 4) impacting the

culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging

dialogue among all community partners to leverage existing programs and introduce new

ones

29th OLYMPIAD

BEIJING CHINA

US wrestling team captain Daniel

Cormier (2115 lbs) hospitalized for

kidney failure as result of

dehydration related to cutting weight

(did not compete)

US boxer Gary Russell was found

unconscious 4 days before his

Olympic bout due to cutting weight

(did not compete)

29th OLYMPIAD

BEIJING CHINA

Michael Phelps

8 Gold Medals SwimmingAge 23

Height 6rsquo4rdquo

Weight 195 lbs

BMI 2374

Daily Food Intake 10375 KCAL

(15 PRO 58 CHO 27 FAT)

Exercise 30 hrswk

2005 USDA FOOD PYRAMID

ldquoThe food pyramid

is too complicated

and has too many

messagesrdquo

Robert Post PhD USDA Deputy

Director 2011

2005 USDA FOOD PYRAMID

ldquoItrsquos going to be hard not to do

better than the current pyramid

which basically conveys no

useful informationrdquo

Walter C Willett MD

Chairman Department of Nutrition

Harvard School of Public Health

2011 USDA MY PLATE

ldquoWe are all

bombarded with so

many dietary

messages that it is

hard to find time to

sort through all this

informationrdquo

Michelle Obama 2011

Dietary Guidelines for Americans

2010 Two Primary Concepts

Maintain calorie balance over time to

achieve and maintain a healthy weight

Focus on consuming nutrient-dense foods

and beverages

Dietary Guidelines for Americans 2010

Efficacy-based comparative dietary guidelines

Carb Fat Pro

Mediterranean Diet 45-55 25-35 20

IOM Dietary Ref Intakes 45-65 25-35 15

NCEP-ATPIII 50-60 25-35 15

Am Dietetic Assoc 45-65 20-35 15

PARADOX OF INCREASING OBESITY

PREVALENCE

bull Focus on healthy eating and physical

activity

bull Awareness of dangers of obesity buthellip

bull Obesity prevalence continues to rise

bull Work amp commuting demands

bull Little time to exercise

bull Little time to prepare food

bull Availability of high-fatcalorie foods

Rationale for community-based interventions

bull Increases in obesity prevalence due to genes

bull Increased calories (eg 200 Kcalday

over 10 years)

bull Increased portion sizes (eg 22 oz

steaks and 44 oz sodas)

bull Western diets in developing nations

increase risk of obesity

READINESS TO CHANGE

ldquoHabit is habit and not to be

flung out of the window but

coaxed downstairs a step at a

timerdquo

Mark Twain

Long-Term Weight Maintenance

National Weight Control Registry (N=10000)

Survey of 3000 members who have been in the

Registry for at least 10 years

Starting weight = 224 lbs Average weight loss=69

lbs

At 5 years participants had maintained an average

weight loss=52 lbs

At 10 years participants had maintained an average

weight loss=51 lbs

Thomas Bond Phelan et al TOS 2011

Long-Term Weight Maintenance

Weight Maintainers report that they usually

Track their food intake

Count calories or fat grams

Follow a low-calorie low fat diet (1800 caloriesday

less than 30 of calories from fat

Eat breakfast regularly

Limit the amount they eat out (about 3 timesweek

eat fast food less than onceweek)

Thomas Bond Phelan et al TOS 2011

Long-Term Weight Maintenance

Weight Maintainers report that they usually

Eat similar food regularly

Donrsquot splurge much on holidays amp special occasions

Walk about one hourday

Watch less than 10 hours of TV a week

Weigh themselves at least once a week

Thomas Bond Phelan et al TOS 2011

LONG-TERM WEIGHT MAINTENANCE

Continued consumption of a low-

calorie diet with moderate fat intake

Limited fast food

High levels of physical activity

Phalen et al Obesity 2006 14 710-716

LONG-TERM WEIGHT MAINTENANCE

Daily weighing improved

maintenance of weight loss

particularly when delivered

face to face

Wing et al NEJM 2006 3551563-1571

Most Promising Strategies For

Preventing Weight Regain

Providing multi-component

programs with ongoing

professional contacts

Physical activityexercise

Portion controlmeal replacements

Extending treatment through

weekly or bi-weekly sessions

Pharmacotherapy

Perri Foreyt amp Anton Preventing Weight Regain After Weight Loss 2008

Most Promising Strategies For

Preventing Weight Regain

Extended treatments have shown

promise in promoting adherence to

the behaviors required for the long-

term maintenance of weight loss

Continuous care approach focused

on reasonable long-term objectives

appears appropriate for most

patients

Perri Foreyt amp Anton Preventing Weight Regain After Weight

Loss 2008

An Example of a successful long-term

intervention

The Look AHEAD Study

Does Weight Loss Reduce

Cardiovascular Disease and Death in

Overweight Individuals with Diabetes

bull Action for HEAlth in Diabetes

bull Objective to examine in overweight

persons with Type 2 Diabetes the long-

term effects of an intensive lifestyle

intervention program compared to

diabetes education and support

bull 16 Centers

bull 5145 overweight volunteers with

diabetes

Look AHEAD

Look AHEAD

Primary End Point Composite

bull Cardiovascular death (including fatal

myocardial infarction and stroke)

bull Non-fatal myocardial infarction

bull Non-fatal stroke

Winston-Salem

Baltimore

Philadelphia

New York

Providence

Boston

Clinical Site Coordinating Center

Clinical Sites

Seattle

Los Angeles

San AntonioHouston

Baton Rouge

Minneapolis

Memphis

Birmingham

Pittsburgh

Denver

Phoenix

Look AHEADParticipants

101100Baseline weight (kg)

589586Age (years)

9496Attended 1 year exam

360359Baseline BMI

1514Insulin Users

3737Minority

6059Women

(N=2574)(N=2630)

DSELifestyle

p lt 0004

Look AHEAD

Study Interventions

bull Diabetes support and education - DSE (control group)

bull Lifestyle intervention ndash ILI (treatment group)

Look AHEAD

Lifestyle Intervention

Goals

bull 7 weight loss for the group (10

for individual)

bull 175 minutes of moderate intensity

activity

Look AHEAD

Lifestyle Intervention

bull Diet

ndash ADA NCEP (lt 30 fat lt 10 sat fat

gt15 protein)

ndash 1200-1500 (if weight lt250lbs)

ndash 1500-1800 (if weight gt250lbs)

ndash During first 4 weeks to 4 months portion

control (liquid meal replacements or

structured meal plan)

Look AHEAD

Lifestyle Intervention

bull Physical Activity

ndash unsupervised

ndash 175 minutes moderate intensityweek

ndash 5 daysweek

ndash walking

Weight Loss at 1-Year

-9

ILI 0

-1

-2

-3

-4

-5

-6

-7

-8

DSE

p lt 00001

W

eig

ht

Chan

ge

86

07

The Look AHEAD Research Group Diabetes Care 2007

Reduction in Initial Weight by Gender

N=872

N=1229N=1197

N=830

-12

-10

-8

-6

-4

-2

0

0 2 4 6 8 10 12

Months

R

ed

uctio

n in

In

itia

l W

eig

ht

Men

Women

Plt0001

The Look AHEAD Research Group Diabetes Care 2007

Fitness Change () at 1-Year

0

5

10

15

20

25

Mean

Fitness C

hange

Unadjusted

Plt0001Adjusted for 1 Year

Weight Change Plt0001

58

209

108

159

DSE ILI ILIDSE

The Look AHEAD Research Group Diabetes Care 2007

1-Year Changes in Markers of

Diabetes Control

Markers of Diabetes

Control ILI DSE P-value

Hemoglobin A1c () BL

Hemoglobin A1c () Y1

Y1 ndash Baseline

725

661

-064

729

715

-014

026

lt0001

lt0001

Fasting glucose (mgdl) BL

Fasting glucose (mgdl) Y1

Y1 ndash Baseline

1519

1304

-215

1536

1464

-72

021

lt0001

lt0001

Diabetes medications BL

Diabetes medications Y1

Y1 ndash Baseline

865

786

-78

865

887

22

093

lt0001

lt0001

1-Year Changes in Markers of

Blood Pressure ControlMarkers of Blood Pressure

Control ILI DSE P-value

Systolic BP (mmHg) BL

Systolic BP (mmHg) Y1

Y1 ndash Baseline

1282

1214

-68

1294

1266

-28

026

lt0001

lt0001

Diastolic BP (mmHg) BL

Diastolic BP (mmHg) Y1

Y1 ndash Baseline

699

670

-30

704

686

-18

011

lt0001

lt0001

Antihypertensive medications BL

Antihypertensive medications Y1

Y1 ndash Baseline

753

752

-01

737

759

22

023

054

002

1-Year Changes in Markers of Lipid

Control

Markers of Lipid Control ILI DSE P-value

LDL-cholesterol (mgdl) BL

LDL-cholesterol (mgdl) Y1

Y1 ndash Baseline

1122

1070

-52

1124

1067

-57

078

074

049

HDL-cholesterol (mgdl) BL

HDL-cholesterol (mgdl) Y1

Y1 ndash Baseline

435

469

34

436

449

14

080

lt0001

lt0001

Triglycerides (mgdl) BL

Triglycerides (mgdl) Y1

Y1 ndash Baseline

1828

1525

-303

1800

1654

-146

038

lt0001

lt0001

Lipid lowering medications BL

Lipid lowering medications Y1

Y1 ndash Baseline

494

530

37

484

578

94

052

lt0001

lt0001

1-Year Changes in Percent of Participants

Meeting ADA Goals

ADA Goal ILI DSE P-value

Hemoglobin A1c lt 7 BL

Hemoglobin A1c lt 7 Y1

Y1 ndash Baseline

463

727

264

454

508

54

050

lt0001

lt0001

Blood pressure lt 13080 mmHg BL

Blood pressure lt 13080 mmHg Y1

Y1 ndash Baseline

535

686

151

499

570

70

001

lt0001

lt0001

LDL-cholesterol lt 100 mgdl BL

LDL-cholesterol lt 100 mgdl Y1

Y1 ndash Baseline

371

438

67

369

449

80

087

045

034

All three goals BL

All three goals Y1

Y1 ndash Baseline

108

236

128

95

160

65

013

lt0001

lt0001

Mean Changes in Weight Fitness amp BP

Averaged Over Four Years

DSE

Mean

ILI

Mean

P-value

Weight Loss

( initial wt)

-088 -615 lt 00001

Fitness

( METS)

196 1274 lt00001

HbA1c -009 -036 lt 00001

SBP (mm Hg) -297 -533 lt 00001

DBP (mm Hg) -248 -292 0012

Look AHEAD Research Group Arch Int Med 2010

Mean Changes in Lipid Profile

Averaged Over Four Years

DSE

Mean

ILI

Mean

P-value

HDL (mgdl) 197 367 lt00001

TG (mgdl) -1975 -2556 00006

LDL (mgdl) -1284 -1127 0009

LDL (mgdl)

(Adjusting for

medication use)

-922 -875 042

Look AHEAD Research Group Arch Int Med 2010

Percent () Completing Outcome

Measures at Years 1-4

Intervention Group

(ILI)

Year 1 971

Year 2 949

Year 3 940

Year 4 941

Comparison Group

(DSE)

Year 1 957

Year 2 935

Year 3 938

Year 4 931

Look AHEAD Summary

ILI had significantly greater improvements than DSE in all CVD risk factors averaged across 4 years (except LDL-C)

There may be long-term beneficial effects from this 4-year period in which ILI subjects have been exposed to lower CVD risk factors

Longer follow-ups will determine whether these lowered CVD risk factors can be maintained amp whether lifestyle intervention has positive effects on CVD morbidity amp mortality

Mary J

Female

White

56 years old at start of Look AHEAD

study

Past Medical History Type 2 diabetes

overweight diverticulosis arthritis

sleep apnea back pain

Mary J

bullLong term strugglesbull Helping youngest daughter with

personal issues and children

bull Rotator cuff problems

bull Degenerative disks in back

bull Rheumatoid arthritis

bull Diabetes

bull Physically demanding job

bull Financial struggles

Pounds

Years

82007 grandkids enter pre-school

Catherine L

Female

White

47 years old at start of Look AHEAD

study

Past Medical History Type 2 diabetes

overweight high blood pressure

hypothyroidism back pain

Catherine L

Long term struggles

bull Motherrsquos declining health and death

bull Multiple serious injuries

bull Sudden death of sister

bull Death of step-father

bull Declining economy

bull Children living at home

Pounds

Years

Realistic Management Goals

5-10 weight loss

Health energy and fitness

Well-being and self-esteem

Mood and appearance

Functional and recreational

activity

Key Elements

Focus on health and energy

Food and physical activity diaries

Gradual increase in physical activity

Gradual reduction in dietary fat

No feelings of food deprivation

Social support groups

Recommended Strategies for Building

Sustainable Healthy Communities

Overview from USA

Promote the availability of affordable healthy

food and beverages

Support healthy food and beverage choices

Encourage breastfeeding

Encourage physical activity or limit sedentary

activity among children amp youth

Create safe communities that support physical

activity

Encourage communities to organize for change

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Increase the availability of healthier food and

beverage choices in public service venues (eg

schools city amp county buildings etc)

--Insufficient evidence in school-based programs

--Associations suggest availability amp increased

consumption

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve availability of affordable healthier

food amp beverage choices in public service

venues

--Reducing the cost of healthier foods

increases their purchase

--Providing coupons redeemable for

healthier foods increases their purchase

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve geographic availability of

supermarkets in underserved areas

-- Greater access to nearby supermarkets is

associated with healthier eating behaviors

-- Increasing the number of supermarkets in

underserved neighborhoods increased

real estate values increased economic

activity amp employment amp resulted in lower

food prices

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Provide incentives to food retailers to locate in

andor offer healthier food choices in

underserved areas

-- Presence of retail venues that provide healthier

foods is associated with better nutrition

-- Greater availability of supermarkets was

associated with lower adolescent BMI scores

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Improve availability of mechanisms for

purchasing foods from farms

--Evidence supporting a direct link between

purchasing food from farms amp improved diet is

limited

--Two studies of initiatives to encourage

participation in farmersrsquo market showed

increased intention to eat more fruits amp

vegetables but no direct evidence

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Provide incentives for the production

distribution and procurement of foods from local

farms

--No evidence has been published to link local

food production amp health outcomes

--There is a current study exploring the potential

nutritional amp health benefits of eating locally

grown foods

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Restrict availability of less healthy foods amp

beverages in public service venues

--No peer-reviewed studies examined the impact

designed to restrict availability of less healthy

foods in public service venues

--21 states have policies that restrict the sale of

competitive foods in schools beyond USDA

regulations however no studies have evaluated

the impact of the policies

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Institute smaller portion size options in public

service venues

--Evidence is lacking to demonstrate effectiveness

of population-based interventions aimed at

reducing portion sizes in public service venues

--Evidence from clinical studies in laboratories

demonstrates decreasing portion sizes

decreases energy intake

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Limit advertisements of less healthy foods amp

beverages

--Little evidence is available regarding the impact

of restricting advertising on purchasing amp

consumption of less healthy foods

--Cross-sectional time-series studies of tobacco-

control efforts suggest an association between

advertising bans amp decreased tobacco

consumption

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Discourage consumption of sugar-sweetened

beverages

--One longitudinal study of a school-based

intervention among Native-American high school

students showed a substantial reduction in

sugar-sweetened beverages over a 3-year

period

--A RCT of a home-based intervention that

eliminated sugar-sweetened beverages showed

reduction in BMI scores

Recommended Community Strategies Strategies to encourage breastfeeding

Increase support for breastfeeding

--Evidence directly linking environmental

interventions that support breastfeeding with

obesity-related outcomes is lacking

--Epidemiologic studies indicate that breastfeeding

helps prevent pediatric obesity

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Require physical education in schools

--14 studies have demonstrated that school-based

PE was effective in increasing levels of physical

activity and improving physical fitness

--Minimum of 150 minwk in elementary schools

225 minwk in middle schools and high schools

throughout the school year as recommended by

NASPE

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Increase opportunities for extracurricular

physical activity

--Participation in after-school programs increased

studentsrsquo level of physical activity amp improved

obesity-related outcomes (improved CV fitness

reduced body fat)

--2 pilot studies providing extracurricular physical

activity showed increased levels of PA amp

decreased sedentary behavior

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Reduce screen time in public service venues

--A school-based RCT indicated that children who

reduced their television videotape amp video

game use had significant decrease in BMI tricep

skin fold thickness amp waist circumference

compared to controls

--Spending less time watching television is

associated with increased physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Improve access to outdoor recreational

facilities

--Review of 108 studies indicated that access to facilities

and programs for recreation near their homes amp time

spent outdoors correlated positively with increased

physical activity among childrenamp adults

--Perceptions that footpaths are safe for walking was

significantly associated with adults being classified as

physically active at a level sufficient for health benefits

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting

bicycling

--Longitudinal intervention studies have

demonstrated that improving bicycling

infrastructure is associated with increased

frequency of bicycling

--Cross-sectional studies indicated a significant

association between bicycling infrastructure amp

frequency of biking

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting walking

--Reviews of cross-sectional studies of

environmental correlates of physical activity amp

walking generally find a positive association

between infrastructure supportive of walking amp

physical activity

--Identifying amp creating safe routes to school

together with educational components

increased the number of students walking to

school

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Locating schools within easy walking

distance of residential areas

--Community-scale urban design amp land use policies amp

practices including locating schools stores workplaces

amp recreation areas close to residential areas are

effective in facilitating an increase in levels of physical

activity

--Majority of efforts to encourage walking to school involve

improving the routes rather than improving the location

of schools

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Improve access to public transportation

--Insufficient evidence exists to determine

effectiveness of transportation policies in

increasing the level of physical activity or

improving fitness

--1 study indicated that 29 of individuals who

walk to and from public transit achieve at least

30 minutes of daily physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Zone for mixed-use development

--Allows residential commercial institutional amp

other public land uses to be located in close

proximity to one another

--Studies using correlation analyses amp regression

models indicated that mixed land use was

associated with increased walking amp cycling

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance personal safety in areas where

persons are or could be physically active

--Cross-sectional studies have demonstrated a

negative relationship between crime rates andor

perceived safety amp physical activity in

neighborhoods

--Few intervention studies have evaluated the

impact of policies amp practices to improve

personal safety on physical activity

Geospatial Mapping Linking Urban

Environments to Health Risk

Measure association between environmental variables amp health risk factors

Assess relationships between variables at different levels of analysis

Used in conjunction with linear analyses

Our Community Environmental Model

of Obesity

Community Factors

Poverty

Crime

Grocery Quality

Restaurants

Parks

Sidewalks

Fast Food Outlets

Recreational

Facilities

Individual Factors

Dietary Intake

Physical Activity

Genetics

Family History

StressCoping

Eating Disorders

Psychological

Problems

Weight

Status

Chosen Neighborhoods

Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped

We then matched census-block groups within the income groups by population density and percentage of minority representation

One matched block group per income level was randomly selected

Prevalence of Obesity in

Block-Groups

0

5

10

15

20

25

30

35

40

45

50

Ag

e-a

dju

sted

Ob

esit

y P

rev

ale

nce

(

)

High-Income Low-Income

Age-standardized to the 1990 US Census

Density of Environmental Factors in the

Community Contributes to a ldquoToxicrdquo

Obesity Environment

0

2

4

6

8

10

12

14

16

18

Fast-food Convenience Store Bars

Den

sity

10

00

perso

ns

High-Income Low-Income

COMMUNITYrsquoS PERCEPTION OF SAFETY

0

5

10

15

20

25

30

35

40

Daytime Nighttime

Perc

en

t (

) F

eeli

ng

So

mew

hat

Safe

or

Un

safe

Low-Income High-Income

Percent Substandard (or worse) Housing

or Ground Conditions

of Residential Properties

0

10

20

30

Structural Grounds

Perc

en

t (

)

Low-Income High-Income

CONCLUSIONS

These data suggest that the higher

frequency of outlets providing

calorically-dense foods and alcohol may

contribute to greater obesity prevalence

in residents of low-income communities

More research is needed to thoroughly

document environmental determinants

of health and obesity

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

From 1994-1998 HUD randomly assigned

4498 women with children living in public

housing in high-poverty urban census

tracts to one of three groups (1) housing

vouchers redeemable only if they moved

to a low-poverty census tract (2)

unrestricted vouchers or (3) control group

(no vouchers)

Ludwig et al NEJM 201136516

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

10-12 year follow-up showed modest but

potentially important reductions in the

prevalence of extreme obesity amp diabetes in the

group moving from a neighborhood with high

poverty on one of low poverty compared to the

control group

No differences between the group receiving

traditional vouchers amp the control group

ldquoNeighborhoods matterrdquo

Ludwig et al NEJM 201136516

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance traffic safety in areas where

persons are or could be physically active

--Community-scale urban design amp land use policies to

promote physical activity including design components

to improve street lighting infrastructure projects to

increase safety of pedestrian street crossing and use of

traffic calming approaches such as speed humps amp

traffic circles are effective in increasing physical activity

--Both community-scale amp street-scale policies amp practices

are effective in increasing physical activity

Recommended Community Strategies Encourage Communities to Organize for Change

Participate in community coalitions or

partnerships to address obesity

--Little evidence is available to determine the

impact of community coalitions on obesity

prevention

--The presence of anti-smoking community

coalitions has been associated with lower rates

of tobacco consumption

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

$103 million awarded to 61 states and

communities including state amp local government

agencies tribes amp territories amp state amp local non-

profit organizations

To build capacity to implement changes for

community prevention efforts to ensure long-

term success

To implement evidence-based and practice-

based programs to improve health amp wellness

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Priority areas are

Tobacco-free living

Active living and healthy eating

Evidence-based quality clinical and other

preventive health services for prevention

and control of high blood pressure and

high cholesterol

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Applicants proposed specific activities in

line with their chosen priority areas in their

applications

Grantee activities will not be finalized until

plans are negotiated with CDC by early

2012

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Capacity-Building Award

The Confederated Tribes of The Chehalis

Reservation is receiving a $498663 planning

award to build capacity to support healthy

lifestyles among their tribal population of 1500

in Washington State

Work will target tobacco-free living active living

and healthy eating and quality clinical and other

healthy serviceswwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Implementation Award

Austin TX Dept of Health and Human Services

is receiving $1026158 to serve Travis County

(Austin) to expand efforts in tobacco-free living

active living and healthy eating quality clinical

and other preventive services social and

emotional wellness and healthy and safe

physical environmentswwwcdcgov1052011

Building sustainable healthy

communities Bottom line

Obesity is an environmental problem

Despite progress in genetic research public health advances only will occur when we take the environment seriously

Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment

Until we do this we will not make substantial progress in addressing the epidemic of obesity

Poston amp Foreyt Atherosclerosis 1999

Whatrsquos the best approach

Integrate all sectors of society into community

change interventions

Incorporate

Science amp Technology

Education

FamilyCommunity

Healthcare

Arts amp Entertainment

Law amp Politics

Commerce amp Trade

Sectors of Society

Arts amp Entertainm

ent

Commerce amp Trade

Education

FamilyCommunity

Healthcare

Law amp Politics

Science amp Technology

Project FIT rationale design and baseline characteristics of a school- and community-

based intervention to address physical activity and healthy eating among low-income

elementary school children

Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D

Oh HJ Orth J Randall S Mayfield K Holmes D

Source

Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu

Abstract

BACKGROUND

This paper describes Project FIT a collaboration between the public school system local

health systems physicians neighborhood associations businesses faith-based leaders

community agencies and university researchers to develop a multi-faceted approach to

promote physical activity and healthy eating toward the general goal of preventing and

reducing childhood obesity among children in Grand Rapids MI USA

METHODSDESIGN

There are four overall components to Project FIT school community social marketing and

school staff wellness - all that focus on 1) increasing access to safe and affordable physical

activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)

improving the affordability and availability of nutritious food in the neighborhoods surrounding

the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding

nutrition and physical activity among school staff parents and students 4) impacting the

culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging

dialogue among all community partners to leverage existing programs and introduce new

ones

29th OLYMPIAD

BEIJING CHINA

Michael Phelps

8 Gold Medals SwimmingAge 23

Height 6rsquo4rdquo

Weight 195 lbs

BMI 2374

Daily Food Intake 10375 KCAL

(15 PRO 58 CHO 27 FAT)

Exercise 30 hrswk

2005 USDA FOOD PYRAMID

ldquoThe food pyramid

is too complicated

and has too many

messagesrdquo

Robert Post PhD USDA Deputy

Director 2011

2005 USDA FOOD PYRAMID

ldquoItrsquos going to be hard not to do

better than the current pyramid

which basically conveys no

useful informationrdquo

Walter C Willett MD

Chairman Department of Nutrition

Harvard School of Public Health

2011 USDA MY PLATE

ldquoWe are all

bombarded with so

many dietary

messages that it is

hard to find time to

sort through all this

informationrdquo

Michelle Obama 2011

Dietary Guidelines for Americans

2010 Two Primary Concepts

Maintain calorie balance over time to

achieve and maintain a healthy weight

Focus on consuming nutrient-dense foods

and beverages

Dietary Guidelines for Americans 2010

Efficacy-based comparative dietary guidelines

Carb Fat Pro

Mediterranean Diet 45-55 25-35 20

IOM Dietary Ref Intakes 45-65 25-35 15

NCEP-ATPIII 50-60 25-35 15

Am Dietetic Assoc 45-65 20-35 15

PARADOX OF INCREASING OBESITY

PREVALENCE

bull Focus on healthy eating and physical

activity

bull Awareness of dangers of obesity buthellip

bull Obesity prevalence continues to rise

bull Work amp commuting demands

bull Little time to exercise

bull Little time to prepare food

bull Availability of high-fatcalorie foods

Rationale for community-based interventions

bull Increases in obesity prevalence due to genes

bull Increased calories (eg 200 Kcalday

over 10 years)

bull Increased portion sizes (eg 22 oz

steaks and 44 oz sodas)

bull Western diets in developing nations

increase risk of obesity

READINESS TO CHANGE

ldquoHabit is habit and not to be

flung out of the window but

coaxed downstairs a step at a

timerdquo

Mark Twain

Long-Term Weight Maintenance

National Weight Control Registry (N=10000)

Survey of 3000 members who have been in the

Registry for at least 10 years

Starting weight = 224 lbs Average weight loss=69

lbs

At 5 years participants had maintained an average

weight loss=52 lbs

At 10 years participants had maintained an average

weight loss=51 lbs

Thomas Bond Phelan et al TOS 2011

Long-Term Weight Maintenance

Weight Maintainers report that they usually

Track their food intake

Count calories or fat grams

Follow a low-calorie low fat diet (1800 caloriesday

less than 30 of calories from fat

Eat breakfast regularly

Limit the amount they eat out (about 3 timesweek

eat fast food less than onceweek)

Thomas Bond Phelan et al TOS 2011

Long-Term Weight Maintenance

Weight Maintainers report that they usually

Eat similar food regularly

Donrsquot splurge much on holidays amp special occasions

Walk about one hourday

Watch less than 10 hours of TV a week

Weigh themselves at least once a week

Thomas Bond Phelan et al TOS 2011

LONG-TERM WEIGHT MAINTENANCE

Continued consumption of a low-

calorie diet with moderate fat intake

Limited fast food

High levels of physical activity

Phalen et al Obesity 2006 14 710-716

LONG-TERM WEIGHT MAINTENANCE

Daily weighing improved

maintenance of weight loss

particularly when delivered

face to face

Wing et al NEJM 2006 3551563-1571

Most Promising Strategies For

Preventing Weight Regain

Providing multi-component

programs with ongoing

professional contacts

Physical activityexercise

Portion controlmeal replacements

Extending treatment through

weekly or bi-weekly sessions

Pharmacotherapy

Perri Foreyt amp Anton Preventing Weight Regain After Weight Loss 2008

Most Promising Strategies For

Preventing Weight Regain

Extended treatments have shown

promise in promoting adherence to

the behaviors required for the long-

term maintenance of weight loss

Continuous care approach focused

on reasonable long-term objectives

appears appropriate for most

patients

Perri Foreyt amp Anton Preventing Weight Regain After Weight

Loss 2008

An Example of a successful long-term

intervention

The Look AHEAD Study

Does Weight Loss Reduce

Cardiovascular Disease and Death in

Overweight Individuals with Diabetes

bull Action for HEAlth in Diabetes

bull Objective to examine in overweight

persons with Type 2 Diabetes the long-

term effects of an intensive lifestyle

intervention program compared to

diabetes education and support

bull 16 Centers

bull 5145 overweight volunteers with

diabetes

Look AHEAD

Look AHEAD

Primary End Point Composite

bull Cardiovascular death (including fatal

myocardial infarction and stroke)

bull Non-fatal myocardial infarction

bull Non-fatal stroke

Winston-Salem

Baltimore

Philadelphia

New York

Providence

Boston

Clinical Site Coordinating Center

Clinical Sites

Seattle

Los Angeles

San AntonioHouston

Baton Rouge

Minneapolis

Memphis

Birmingham

Pittsburgh

Denver

Phoenix

Look AHEADParticipants

101100Baseline weight (kg)

589586Age (years)

9496Attended 1 year exam

360359Baseline BMI

1514Insulin Users

3737Minority

6059Women

(N=2574)(N=2630)

DSELifestyle

p lt 0004

Look AHEAD

Study Interventions

bull Diabetes support and education - DSE (control group)

bull Lifestyle intervention ndash ILI (treatment group)

Look AHEAD

Lifestyle Intervention

Goals

bull 7 weight loss for the group (10

for individual)

bull 175 minutes of moderate intensity

activity

Look AHEAD

Lifestyle Intervention

bull Diet

ndash ADA NCEP (lt 30 fat lt 10 sat fat

gt15 protein)

ndash 1200-1500 (if weight lt250lbs)

ndash 1500-1800 (if weight gt250lbs)

ndash During first 4 weeks to 4 months portion

control (liquid meal replacements or

structured meal plan)

Look AHEAD

Lifestyle Intervention

bull Physical Activity

ndash unsupervised

ndash 175 minutes moderate intensityweek

ndash 5 daysweek

ndash walking

Weight Loss at 1-Year

-9

ILI 0

-1

-2

-3

-4

-5

-6

-7

-8

DSE

p lt 00001

W

eig

ht

Chan

ge

86

07

The Look AHEAD Research Group Diabetes Care 2007

Reduction in Initial Weight by Gender

N=872

N=1229N=1197

N=830

-12

-10

-8

-6

-4

-2

0

0 2 4 6 8 10 12

Months

R

ed

uctio

n in

In

itia

l W

eig

ht

Men

Women

Plt0001

The Look AHEAD Research Group Diabetes Care 2007

Fitness Change () at 1-Year

0

5

10

15

20

25

Mean

Fitness C

hange

Unadjusted

Plt0001Adjusted for 1 Year

Weight Change Plt0001

58

209

108

159

DSE ILI ILIDSE

The Look AHEAD Research Group Diabetes Care 2007

1-Year Changes in Markers of

Diabetes Control

Markers of Diabetes

Control ILI DSE P-value

Hemoglobin A1c () BL

Hemoglobin A1c () Y1

Y1 ndash Baseline

725

661

-064

729

715

-014

026

lt0001

lt0001

Fasting glucose (mgdl) BL

Fasting glucose (mgdl) Y1

Y1 ndash Baseline

1519

1304

-215

1536

1464

-72

021

lt0001

lt0001

Diabetes medications BL

Diabetes medications Y1

Y1 ndash Baseline

865

786

-78

865

887

22

093

lt0001

lt0001

1-Year Changes in Markers of

Blood Pressure ControlMarkers of Blood Pressure

Control ILI DSE P-value

Systolic BP (mmHg) BL

Systolic BP (mmHg) Y1

Y1 ndash Baseline

1282

1214

-68

1294

1266

-28

026

lt0001

lt0001

Diastolic BP (mmHg) BL

Diastolic BP (mmHg) Y1

Y1 ndash Baseline

699

670

-30

704

686

-18

011

lt0001

lt0001

Antihypertensive medications BL

Antihypertensive medications Y1

Y1 ndash Baseline

753

752

-01

737

759

22

023

054

002

1-Year Changes in Markers of Lipid

Control

Markers of Lipid Control ILI DSE P-value

LDL-cholesterol (mgdl) BL

LDL-cholesterol (mgdl) Y1

Y1 ndash Baseline

1122

1070

-52

1124

1067

-57

078

074

049

HDL-cholesterol (mgdl) BL

HDL-cholesterol (mgdl) Y1

Y1 ndash Baseline

435

469

34

436

449

14

080

lt0001

lt0001

Triglycerides (mgdl) BL

Triglycerides (mgdl) Y1

Y1 ndash Baseline

1828

1525

-303

1800

1654

-146

038

lt0001

lt0001

Lipid lowering medications BL

Lipid lowering medications Y1

Y1 ndash Baseline

494

530

37

484

578

94

052

lt0001

lt0001

1-Year Changes in Percent of Participants

Meeting ADA Goals

ADA Goal ILI DSE P-value

Hemoglobin A1c lt 7 BL

Hemoglobin A1c lt 7 Y1

Y1 ndash Baseline

463

727

264

454

508

54

050

lt0001

lt0001

Blood pressure lt 13080 mmHg BL

Blood pressure lt 13080 mmHg Y1

Y1 ndash Baseline

535

686

151

499

570

70

001

lt0001

lt0001

LDL-cholesterol lt 100 mgdl BL

LDL-cholesterol lt 100 mgdl Y1

Y1 ndash Baseline

371

438

67

369

449

80

087

045

034

All three goals BL

All three goals Y1

Y1 ndash Baseline

108

236

128

95

160

65

013

lt0001

lt0001

Mean Changes in Weight Fitness amp BP

Averaged Over Four Years

DSE

Mean

ILI

Mean

P-value

Weight Loss

( initial wt)

-088 -615 lt 00001

Fitness

( METS)

196 1274 lt00001

HbA1c -009 -036 lt 00001

SBP (mm Hg) -297 -533 lt 00001

DBP (mm Hg) -248 -292 0012

Look AHEAD Research Group Arch Int Med 2010

Mean Changes in Lipid Profile

Averaged Over Four Years

DSE

Mean

ILI

Mean

P-value

HDL (mgdl) 197 367 lt00001

TG (mgdl) -1975 -2556 00006

LDL (mgdl) -1284 -1127 0009

LDL (mgdl)

(Adjusting for

medication use)

-922 -875 042

Look AHEAD Research Group Arch Int Med 2010

Percent () Completing Outcome

Measures at Years 1-4

Intervention Group

(ILI)

Year 1 971

Year 2 949

Year 3 940

Year 4 941

Comparison Group

(DSE)

Year 1 957

Year 2 935

Year 3 938

Year 4 931

Look AHEAD Summary

ILI had significantly greater improvements than DSE in all CVD risk factors averaged across 4 years (except LDL-C)

There may be long-term beneficial effects from this 4-year period in which ILI subjects have been exposed to lower CVD risk factors

Longer follow-ups will determine whether these lowered CVD risk factors can be maintained amp whether lifestyle intervention has positive effects on CVD morbidity amp mortality

Mary J

Female

White

56 years old at start of Look AHEAD

study

Past Medical History Type 2 diabetes

overweight diverticulosis arthritis

sleep apnea back pain

Mary J

bullLong term strugglesbull Helping youngest daughter with

personal issues and children

bull Rotator cuff problems

bull Degenerative disks in back

bull Rheumatoid arthritis

bull Diabetes

bull Physically demanding job

bull Financial struggles

Pounds

Years

82007 grandkids enter pre-school

Catherine L

Female

White

47 years old at start of Look AHEAD

study

Past Medical History Type 2 diabetes

overweight high blood pressure

hypothyroidism back pain

Catherine L

Long term struggles

bull Motherrsquos declining health and death

bull Multiple serious injuries

bull Sudden death of sister

bull Death of step-father

bull Declining economy

bull Children living at home

Pounds

Years

Realistic Management Goals

5-10 weight loss

Health energy and fitness

Well-being and self-esteem

Mood and appearance

Functional and recreational

activity

Key Elements

Focus on health and energy

Food and physical activity diaries

Gradual increase in physical activity

Gradual reduction in dietary fat

No feelings of food deprivation

Social support groups

Recommended Strategies for Building

Sustainable Healthy Communities

Overview from USA

Promote the availability of affordable healthy

food and beverages

Support healthy food and beverage choices

Encourage breastfeeding

Encourage physical activity or limit sedentary

activity among children amp youth

Create safe communities that support physical

activity

Encourage communities to organize for change

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Increase the availability of healthier food and

beverage choices in public service venues (eg

schools city amp county buildings etc)

--Insufficient evidence in school-based programs

--Associations suggest availability amp increased

consumption

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve availability of affordable healthier

food amp beverage choices in public service

venues

--Reducing the cost of healthier foods

increases their purchase

--Providing coupons redeemable for

healthier foods increases their purchase

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve geographic availability of

supermarkets in underserved areas

-- Greater access to nearby supermarkets is

associated with healthier eating behaviors

-- Increasing the number of supermarkets in

underserved neighborhoods increased

real estate values increased economic

activity amp employment amp resulted in lower

food prices

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Provide incentives to food retailers to locate in

andor offer healthier food choices in

underserved areas

-- Presence of retail venues that provide healthier

foods is associated with better nutrition

-- Greater availability of supermarkets was

associated with lower adolescent BMI scores

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Improve availability of mechanisms for

purchasing foods from farms

--Evidence supporting a direct link between

purchasing food from farms amp improved diet is

limited

--Two studies of initiatives to encourage

participation in farmersrsquo market showed

increased intention to eat more fruits amp

vegetables but no direct evidence

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Provide incentives for the production

distribution and procurement of foods from local

farms

--No evidence has been published to link local

food production amp health outcomes

--There is a current study exploring the potential

nutritional amp health benefits of eating locally

grown foods

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Restrict availability of less healthy foods amp

beverages in public service venues

--No peer-reviewed studies examined the impact

designed to restrict availability of less healthy

foods in public service venues

--21 states have policies that restrict the sale of

competitive foods in schools beyond USDA

regulations however no studies have evaluated

the impact of the policies

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Institute smaller portion size options in public

service venues

--Evidence is lacking to demonstrate effectiveness

of population-based interventions aimed at

reducing portion sizes in public service venues

--Evidence from clinical studies in laboratories

demonstrates decreasing portion sizes

decreases energy intake

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Limit advertisements of less healthy foods amp

beverages

--Little evidence is available regarding the impact

of restricting advertising on purchasing amp

consumption of less healthy foods

--Cross-sectional time-series studies of tobacco-

control efforts suggest an association between

advertising bans amp decreased tobacco

consumption

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Discourage consumption of sugar-sweetened

beverages

--One longitudinal study of a school-based

intervention among Native-American high school

students showed a substantial reduction in

sugar-sweetened beverages over a 3-year

period

--A RCT of a home-based intervention that

eliminated sugar-sweetened beverages showed

reduction in BMI scores

Recommended Community Strategies Strategies to encourage breastfeeding

Increase support for breastfeeding

--Evidence directly linking environmental

interventions that support breastfeeding with

obesity-related outcomes is lacking

--Epidemiologic studies indicate that breastfeeding

helps prevent pediatric obesity

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Require physical education in schools

--14 studies have demonstrated that school-based

PE was effective in increasing levels of physical

activity and improving physical fitness

--Minimum of 150 minwk in elementary schools

225 minwk in middle schools and high schools

throughout the school year as recommended by

NASPE

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Increase opportunities for extracurricular

physical activity

--Participation in after-school programs increased

studentsrsquo level of physical activity amp improved

obesity-related outcomes (improved CV fitness

reduced body fat)

--2 pilot studies providing extracurricular physical

activity showed increased levels of PA amp

decreased sedentary behavior

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Reduce screen time in public service venues

--A school-based RCT indicated that children who

reduced their television videotape amp video

game use had significant decrease in BMI tricep

skin fold thickness amp waist circumference

compared to controls

--Spending less time watching television is

associated with increased physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Improve access to outdoor recreational

facilities

--Review of 108 studies indicated that access to facilities

and programs for recreation near their homes amp time

spent outdoors correlated positively with increased

physical activity among childrenamp adults

--Perceptions that footpaths are safe for walking was

significantly associated with adults being classified as

physically active at a level sufficient for health benefits

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting

bicycling

--Longitudinal intervention studies have

demonstrated that improving bicycling

infrastructure is associated with increased

frequency of bicycling

--Cross-sectional studies indicated a significant

association between bicycling infrastructure amp

frequency of biking

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting walking

--Reviews of cross-sectional studies of

environmental correlates of physical activity amp

walking generally find a positive association

between infrastructure supportive of walking amp

physical activity

--Identifying amp creating safe routes to school

together with educational components

increased the number of students walking to

school

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Locating schools within easy walking

distance of residential areas

--Community-scale urban design amp land use policies amp

practices including locating schools stores workplaces

amp recreation areas close to residential areas are

effective in facilitating an increase in levels of physical

activity

--Majority of efforts to encourage walking to school involve

improving the routes rather than improving the location

of schools

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Improve access to public transportation

--Insufficient evidence exists to determine

effectiveness of transportation policies in

increasing the level of physical activity or

improving fitness

--1 study indicated that 29 of individuals who

walk to and from public transit achieve at least

30 minutes of daily physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Zone for mixed-use development

--Allows residential commercial institutional amp

other public land uses to be located in close

proximity to one another

--Studies using correlation analyses amp regression

models indicated that mixed land use was

associated with increased walking amp cycling

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance personal safety in areas where

persons are or could be physically active

--Cross-sectional studies have demonstrated a

negative relationship between crime rates andor

perceived safety amp physical activity in

neighborhoods

--Few intervention studies have evaluated the

impact of policies amp practices to improve

personal safety on physical activity

Geospatial Mapping Linking Urban

Environments to Health Risk

Measure association between environmental variables amp health risk factors

Assess relationships between variables at different levels of analysis

Used in conjunction with linear analyses

Our Community Environmental Model

of Obesity

Community Factors

Poverty

Crime

Grocery Quality

Restaurants

Parks

Sidewalks

Fast Food Outlets

Recreational

Facilities

Individual Factors

Dietary Intake

Physical Activity

Genetics

Family History

StressCoping

Eating Disorders

Psychological

Problems

Weight

Status

Chosen Neighborhoods

Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped

We then matched census-block groups within the income groups by population density and percentage of minority representation

One matched block group per income level was randomly selected

Prevalence of Obesity in

Block-Groups

0

5

10

15

20

25

30

35

40

45

50

Ag

e-a

dju

sted

Ob

esit

y P

rev

ale

nce

(

)

High-Income Low-Income

Age-standardized to the 1990 US Census

Density of Environmental Factors in the

Community Contributes to a ldquoToxicrdquo

Obesity Environment

0

2

4

6

8

10

12

14

16

18

Fast-food Convenience Store Bars

Den

sity

10

00

perso

ns

High-Income Low-Income

COMMUNITYrsquoS PERCEPTION OF SAFETY

0

5

10

15

20

25

30

35

40

Daytime Nighttime

Perc

en

t (

) F

eeli

ng

So

mew

hat

Safe

or

Un

safe

Low-Income High-Income

Percent Substandard (or worse) Housing

or Ground Conditions

of Residential Properties

0

10

20

30

Structural Grounds

Perc

en

t (

)

Low-Income High-Income

CONCLUSIONS

These data suggest that the higher

frequency of outlets providing

calorically-dense foods and alcohol may

contribute to greater obesity prevalence

in residents of low-income communities

More research is needed to thoroughly

document environmental determinants

of health and obesity

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

From 1994-1998 HUD randomly assigned

4498 women with children living in public

housing in high-poverty urban census

tracts to one of three groups (1) housing

vouchers redeemable only if they moved

to a low-poverty census tract (2)

unrestricted vouchers or (3) control group

(no vouchers)

Ludwig et al NEJM 201136516

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

10-12 year follow-up showed modest but

potentially important reductions in the

prevalence of extreme obesity amp diabetes in the

group moving from a neighborhood with high

poverty on one of low poverty compared to the

control group

No differences between the group receiving

traditional vouchers amp the control group

ldquoNeighborhoods matterrdquo

Ludwig et al NEJM 201136516

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance traffic safety in areas where

persons are or could be physically active

--Community-scale urban design amp land use policies to

promote physical activity including design components

to improve street lighting infrastructure projects to

increase safety of pedestrian street crossing and use of

traffic calming approaches such as speed humps amp

traffic circles are effective in increasing physical activity

--Both community-scale amp street-scale policies amp practices

are effective in increasing physical activity

Recommended Community Strategies Encourage Communities to Organize for Change

Participate in community coalitions or

partnerships to address obesity

--Little evidence is available to determine the

impact of community coalitions on obesity

prevention

--The presence of anti-smoking community

coalitions has been associated with lower rates

of tobacco consumption

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

$103 million awarded to 61 states and

communities including state amp local government

agencies tribes amp territories amp state amp local non-

profit organizations

To build capacity to implement changes for

community prevention efforts to ensure long-

term success

To implement evidence-based and practice-

based programs to improve health amp wellness

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Priority areas are

Tobacco-free living

Active living and healthy eating

Evidence-based quality clinical and other

preventive health services for prevention

and control of high blood pressure and

high cholesterol

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Applicants proposed specific activities in

line with their chosen priority areas in their

applications

Grantee activities will not be finalized until

plans are negotiated with CDC by early

2012

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Capacity-Building Award

The Confederated Tribes of The Chehalis

Reservation is receiving a $498663 planning

award to build capacity to support healthy

lifestyles among their tribal population of 1500

in Washington State

Work will target tobacco-free living active living

and healthy eating and quality clinical and other

healthy serviceswwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Implementation Award

Austin TX Dept of Health and Human Services

is receiving $1026158 to serve Travis County

(Austin) to expand efforts in tobacco-free living

active living and healthy eating quality clinical

and other preventive services social and

emotional wellness and healthy and safe

physical environmentswwwcdcgov1052011

Building sustainable healthy

communities Bottom line

Obesity is an environmental problem

Despite progress in genetic research public health advances only will occur when we take the environment seriously

Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment

Until we do this we will not make substantial progress in addressing the epidemic of obesity

Poston amp Foreyt Atherosclerosis 1999

Whatrsquos the best approach

Integrate all sectors of society into community

change interventions

Incorporate

Science amp Technology

Education

FamilyCommunity

Healthcare

Arts amp Entertainment

Law amp Politics

Commerce amp Trade

Sectors of Society

Arts amp Entertainm

ent

Commerce amp Trade

Education

FamilyCommunity

Healthcare

Law amp Politics

Science amp Technology

Project FIT rationale design and baseline characteristics of a school- and community-

based intervention to address physical activity and healthy eating among low-income

elementary school children

Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D

Oh HJ Orth J Randall S Mayfield K Holmes D

Source

Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu

Abstract

BACKGROUND

This paper describes Project FIT a collaboration between the public school system local

health systems physicians neighborhood associations businesses faith-based leaders

community agencies and university researchers to develop a multi-faceted approach to

promote physical activity and healthy eating toward the general goal of preventing and

reducing childhood obesity among children in Grand Rapids MI USA

METHODSDESIGN

There are four overall components to Project FIT school community social marketing and

school staff wellness - all that focus on 1) increasing access to safe and affordable physical

activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)

improving the affordability and availability of nutritious food in the neighborhoods surrounding

the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding

nutrition and physical activity among school staff parents and students 4) impacting the

culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging

dialogue among all community partners to leverage existing programs and introduce new

ones

2005 USDA FOOD PYRAMID

ldquoThe food pyramid

is too complicated

and has too many

messagesrdquo

Robert Post PhD USDA Deputy

Director 2011

2005 USDA FOOD PYRAMID

ldquoItrsquos going to be hard not to do

better than the current pyramid

which basically conveys no

useful informationrdquo

Walter C Willett MD

Chairman Department of Nutrition

Harvard School of Public Health

2011 USDA MY PLATE

ldquoWe are all

bombarded with so

many dietary

messages that it is

hard to find time to

sort through all this

informationrdquo

Michelle Obama 2011

Dietary Guidelines for Americans

2010 Two Primary Concepts

Maintain calorie balance over time to

achieve and maintain a healthy weight

Focus on consuming nutrient-dense foods

and beverages

Dietary Guidelines for Americans 2010

Efficacy-based comparative dietary guidelines

Carb Fat Pro

Mediterranean Diet 45-55 25-35 20

IOM Dietary Ref Intakes 45-65 25-35 15

NCEP-ATPIII 50-60 25-35 15

Am Dietetic Assoc 45-65 20-35 15

PARADOX OF INCREASING OBESITY

PREVALENCE

bull Focus on healthy eating and physical

activity

bull Awareness of dangers of obesity buthellip

bull Obesity prevalence continues to rise

bull Work amp commuting demands

bull Little time to exercise

bull Little time to prepare food

bull Availability of high-fatcalorie foods

Rationale for community-based interventions

bull Increases in obesity prevalence due to genes

bull Increased calories (eg 200 Kcalday

over 10 years)

bull Increased portion sizes (eg 22 oz

steaks and 44 oz sodas)

bull Western diets in developing nations

increase risk of obesity

READINESS TO CHANGE

ldquoHabit is habit and not to be

flung out of the window but

coaxed downstairs a step at a

timerdquo

Mark Twain

Long-Term Weight Maintenance

National Weight Control Registry (N=10000)

Survey of 3000 members who have been in the

Registry for at least 10 years

Starting weight = 224 lbs Average weight loss=69

lbs

At 5 years participants had maintained an average

weight loss=52 lbs

At 10 years participants had maintained an average

weight loss=51 lbs

Thomas Bond Phelan et al TOS 2011

Long-Term Weight Maintenance

Weight Maintainers report that they usually

Track their food intake

Count calories or fat grams

Follow a low-calorie low fat diet (1800 caloriesday

less than 30 of calories from fat

Eat breakfast regularly

Limit the amount they eat out (about 3 timesweek

eat fast food less than onceweek)

Thomas Bond Phelan et al TOS 2011

Long-Term Weight Maintenance

Weight Maintainers report that they usually

Eat similar food regularly

Donrsquot splurge much on holidays amp special occasions

Walk about one hourday

Watch less than 10 hours of TV a week

Weigh themselves at least once a week

Thomas Bond Phelan et al TOS 2011

LONG-TERM WEIGHT MAINTENANCE

Continued consumption of a low-

calorie diet with moderate fat intake

Limited fast food

High levels of physical activity

Phalen et al Obesity 2006 14 710-716

LONG-TERM WEIGHT MAINTENANCE

Daily weighing improved

maintenance of weight loss

particularly when delivered

face to face

Wing et al NEJM 2006 3551563-1571

Most Promising Strategies For

Preventing Weight Regain

Providing multi-component

programs with ongoing

professional contacts

Physical activityexercise

Portion controlmeal replacements

Extending treatment through

weekly or bi-weekly sessions

Pharmacotherapy

Perri Foreyt amp Anton Preventing Weight Regain After Weight Loss 2008

Most Promising Strategies For

Preventing Weight Regain

Extended treatments have shown

promise in promoting adherence to

the behaviors required for the long-

term maintenance of weight loss

Continuous care approach focused

on reasonable long-term objectives

appears appropriate for most

patients

Perri Foreyt amp Anton Preventing Weight Regain After Weight

Loss 2008

An Example of a successful long-term

intervention

The Look AHEAD Study

Does Weight Loss Reduce

Cardiovascular Disease and Death in

Overweight Individuals with Diabetes

bull Action for HEAlth in Diabetes

bull Objective to examine in overweight

persons with Type 2 Diabetes the long-

term effects of an intensive lifestyle

intervention program compared to

diabetes education and support

bull 16 Centers

bull 5145 overweight volunteers with

diabetes

Look AHEAD

Look AHEAD

Primary End Point Composite

bull Cardiovascular death (including fatal

myocardial infarction and stroke)

bull Non-fatal myocardial infarction

bull Non-fatal stroke

Winston-Salem

Baltimore

Philadelphia

New York

Providence

Boston

Clinical Site Coordinating Center

Clinical Sites

Seattle

Los Angeles

San AntonioHouston

Baton Rouge

Minneapolis

Memphis

Birmingham

Pittsburgh

Denver

Phoenix

Look AHEADParticipants

101100Baseline weight (kg)

589586Age (years)

9496Attended 1 year exam

360359Baseline BMI

1514Insulin Users

3737Minority

6059Women

(N=2574)(N=2630)

DSELifestyle

p lt 0004

Look AHEAD

Study Interventions

bull Diabetes support and education - DSE (control group)

bull Lifestyle intervention ndash ILI (treatment group)

Look AHEAD

Lifestyle Intervention

Goals

bull 7 weight loss for the group (10

for individual)

bull 175 minutes of moderate intensity

activity

Look AHEAD

Lifestyle Intervention

bull Diet

ndash ADA NCEP (lt 30 fat lt 10 sat fat

gt15 protein)

ndash 1200-1500 (if weight lt250lbs)

ndash 1500-1800 (if weight gt250lbs)

ndash During first 4 weeks to 4 months portion

control (liquid meal replacements or

structured meal plan)

Look AHEAD

Lifestyle Intervention

bull Physical Activity

ndash unsupervised

ndash 175 minutes moderate intensityweek

ndash 5 daysweek

ndash walking

Weight Loss at 1-Year

-9

ILI 0

-1

-2

-3

-4

-5

-6

-7

-8

DSE

p lt 00001

W

eig

ht

Chan

ge

86

07

The Look AHEAD Research Group Diabetes Care 2007

Reduction in Initial Weight by Gender

N=872

N=1229N=1197

N=830

-12

-10

-8

-6

-4

-2

0

0 2 4 6 8 10 12

Months

R

ed

uctio

n in

In

itia

l W

eig

ht

Men

Women

Plt0001

The Look AHEAD Research Group Diabetes Care 2007

Fitness Change () at 1-Year

0

5

10

15

20

25

Mean

Fitness C

hange

Unadjusted

Plt0001Adjusted for 1 Year

Weight Change Plt0001

58

209

108

159

DSE ILI ILIDSE

The Look AHEAD Research Group Diabetes Care 2007

1-Year Changes in Markers of

Diabetes Control

Markers of Diabetes

Control ILI DSE P-value

Hemoglobin A1c () BL

Hemoglobin A1c () Y1

Y1 ndash Baseline

725

661

-064

729

715

-014

026

lt0001

lt0001

Fasting glucose (mgdl) BL

Fasting glucose (mgdl) Y1

Y1 ndash Baseline

1519

1304

-215

1536

1464

-72

021

lt0001

lt0001

Diabetes medications BL

Diabetes medications Y1

Y1 ndash Baseline

865

786

-78

865

887

22

093

lt0001

lt0001

1-Year Changes in Markers of

Blood Pressure ControlMarkers of Blood Pressure

Control ILI DSE P-value

Systolic BP (mmHg) BL

Systolic BP (mmHg) Y1

Y1 ndash Baseline

1282

1214

-68

1294

1266

-28

026

lt0001

lt0001

Diastolic BP (mmHg) BL

Diastolic BP (mmHg) Y1

Y1 ndash Baseline

699

670

-30

704

686

-18

011

lt0001

lt0001

Antihypertensive medications BL

Antihypertensive medications Y1

Y1 ndash Baseline

753

752

-01

737

759

22

023

054

002

1-Year Changes in Markers of Lipid

Control

Markers of Lipid Control ILI DSE P-value

LDL-cholesterol (mgdl) BL

LDL-cholesterol (mgdl) Y1

Y1 ndash Baseline

1122

1070

-52

1124

1067

-57

078

074

049

HDL-cholesterol (mgdl) BL

HDL-cholesterol (mgdl) Y1

Y1 ndash Baseline

435

469

34

436

449

14

080

lt0001

lt0001

Triglycerides (mgdl) BL

Triglycerides (mgdl) Y1

Y1 ndash Baseline

1828

1525

-303

1800

1654

-146

038

lt0001

lt0001

Lipid lowering medications BL

Lipid lowering medications Y1

Y1 ndash Baseline

494

530

37

484

578

94

052

lt0001

lt0001

1-Year Changes in Percent of Participants

Meeting ADA Goals

ADA Goal ILI DSE P-value

Hemoglobin A1c lt 7 BL

Hemoglobin A1c lt 7 Y1

Y1 ndash Baseline

463

727

264

454

508

54

050

lt0001

lt0001

Blood pressure lt 13080 mmHg BL

Blood pressure lt 13080 mmHg Y1

Y1 ndash Baseline

535

686

151

499

570

70

001

lt0001

lt0001

LDL-cholesterol lt 100 mgdl BL

LDL-cholesterol lt 100 mgdl Y1

Y1 ndash Baseline

371

438

67

369

449

80

087

045

034

All three goals BL

All three goals Y1

Y1 ndash Baseline

108

236

128

95

160

65

013

lt0001

lt0001

Mean Changes in Weight Fitness amp BP

Averaged Over Four Years

DSE

Mean

ILI

Mean

P-value

Weight Loss

( initial wt)

-088 -615 lt 00001

Fitness

( METS)

196 1274 lt00001

HbA1c -009 -036 lt 00001

SBP (mm Hg) -297 -533 lt 00001

DBP (mm Hg) -248 -292 0012

Look AHEAD Research Group Arch Int Med 2010

Mean Changes in Lipid Profile

Averaged Over Four Years

DSE

Mean

ILI

Mean

P-value

HDL (mgdl) 197 367 lt00001

TG (mgdl) -1975 -2556 00006

LDL (mgdl) -1284 -1127 0009

LDL (mgdl)

(Adjusting for

medication use)

-922 -875 042

Look AHEAD Research Group Arch Int Med 2010

Percent () Completing Outcome

Measures at Years 1-4

Intervention Group

(ILI)

Year 1 971

Year 2 949

Year 3 940

Year 4 941

Comparison Group

(DSE)

Year 1 957

Year 2 935

Year 3 938

Year 4 931

Look AHEAD Summary

ILI had significantly greater improvements than DSE in all CVD risk factors averaged across 4 years (except LDL-C)

There may be long-term beneficial effects from this 4-year period in which ILI subjects have been exposed to lower CVD risk factors

Longer follow-ups will determine whether these lowered CVD risk factors can be maintained amp whether lifestyle intervention has positive effects on CVD morbidity amp mortality

Mary J

Female

White

56 years old at start of Look AHEAD

study

Past Medical History Type 2 diabetes

overweight diverticulosis arthritis

sleep apnea back pain

Mary J

bullLong term strugglesbull Helping youngest daughter with

personal issues and children

bull Rotator cuff problems

bull Degenerative disks in back

bull Rheumatoid arthritis

bull Diabetes

bull Physically demanding job

bull Financial struggles

Pounds

Years

82007 grandkids enter pre-school

Catherine L

Female

White

47 years old at start of Look AHEAD

study

Past Medical History Type 2 diabetes

overweight high blood pressure

hypothyroidism back pain

Catherine L

Long term struggles

bull Motherrsquos declining health and death

bull Multiple serious injuries

bull Sudden death of sister

bull Death of step-father

bull Declining economy

bull Children living at home

Pounds

Years

Realistic Management Goals

5-10 weight loss

Health energy and fitness

Well-being and self-esteem

Mood and appearance

Functional and recreational

activity

Key Elements

Focus on health and energy

Food and physical activity diaries

Gradual increase in physical activity

Gradual reduction in dietary fat

No feelings of food deprivation

Social support groups

Recommended Strategies for Building

Sustainable Healthy Communities

Overview from USA

Promote the availability of affordable healthy

food and beverages

Support healthy food and beverage choices

Encourage breastfeeding

Encourage physical activity or limit sedentary

activity among children amp youth

Create safe communities that support physical

activity

Encourage communities to organize for change

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Increase the availability of healthier food and

beverage choices in public service venues (eg

schools city amp county buildings etc)

--Insufficient evidence in school-based programs

--Associations suggest availability amp increased

consumption

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve availability of affordable healthier

food amp beverage choices in public service

venues

--Reducing the cost of healthier foods

increases their purchase

--Providing coupons redeemable for

healthier foods increases their purchase

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve geographic availability of

supermarkets in underserved areas

-- Greater access to nearby supermarkets is

associated with healthier eating behaviors

-- Increasing the number of supermarkets in

underserved neighborhoods increased

real estate values increased economic

activity amp employment amp resulted in lower

food prices

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Provide incentives to food retailers to locate in

andor offer healthier food choices in

underserved areas

-- Presence of retail venues that provide healthier

foods is associated with better nutrition

-- Greater availability of supermarkets was

associated with lower adolescent BMI scores

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Improve availability of mechanisms for

purchasing foods from farms

--Evidence supporting a direct link between

purchasing food from farms amp improved diet is

limited

--Two studies of initiatives to encourage

participation in farmersrsquo market showed

increased intention to eat more fruits amp

vegetables but no direct evidence

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Provide incentives for the production

distribution and procurement of foods from local

farms

--No evidence has been published to link local

food production amp health outcomes

--There is a current study exploring the potential

nutritional amp health benefits of eating locally

grown foods

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Restrict availability of less healthy foods amp

beverages in public service venues

--No peer-reviewed studies examined the impact

designed to restrict availability of less healthy

foods in public service venues

--21 states have policies that restrict the sale of

competitive foods in schools beyond USDA

regulations however no studies have evaluated

the impact of the policies

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Institute smaller portion size options in public

service venues

--Evidence is lacking to demonstrate effectiveness

of population-based interventions aimed at

reducing portion sizes in public service venues

--Evidence from clinical studies in laboratories

demonstrates decreasing portion sizes

decreases energy intake

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Limit advertisements of less healthy foods amp

beverages

--Little evidence is available regarding the impact

of restricting advertising on purchasing amp

consumption of less healthy foods

--Cross-sectional time-series studies of tobacco-

control efforts suggest an association between

advertising bans amp decreased tobacco

consumption

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Discourage consumption of sugar-sweetened

beverages

--One longitudinal study of a school-based

intervention among Native-American high school

students showed a substantial reduction in

sugar-sweetened beverages over a 3-year

period

--A RCT of a home-based intervention that

eliminated sugar-sweetened beverages showed

reduction in BMI scores

Recommended Community Strategies Strategies to encourage breastfeeding

Increase support for breastfeeding

--Evidence directly linking environmental

interventions that support breastfeeding with

obesity-related outcomes is lacking

--Epidemiologic studies indicate that breastfeeding

helps prevent pediatric obesity

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Require physical education in schools

--14 studies have demonstrated that school-based

PE was effective in increasing levels of physical

activity and improving physical fitness

--Minimum of 150 minwk in elementary schools

225 minwk in middle schools and high schools

throughout the school year as recommended by

NASPE

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Increase opportunities for extracurricular

physical activity

--Participation in after-school programs increased

studentsrsquo level of physical activity amp improved

obesity-related outcomes (improved CV fitness

reduced body fat)

--2 pilot studies providing extracurricular physical

activity showed increased levels of PA amp

decreased sedentary behavior

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Reduce screen time in public service venues

--A school-based RCT indicated that children who

reduced their television videotape amp video

game use had significant decrease in BMI tricep

skin fold thickness amp waist circumference

compared to controls

--Spending less time watching television is

associated with increased physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Improve access to outdoor recreational

facilities

--Review of 108 studies indicated that access to facilities

and programs for recreation near their homes amp time

spent outdoors correlated positively with increased

physical activity among childrenamp adults

--Perceptions that footpaths are safe for walking was

significantly associated with adults being classified as

physically active at a level sufficient for health benefits

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting

bicycling

--Longitudinal intervention studies have

demonstrated that improving bicycling

infrastructure is associated with increased

frequency of bicycling

--Cross-sectional studies indicated a significant

association between bicycling infrastructure amp

frequency of biking

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting walking

--Reviews of cross-sectional studies of

environmental correlates of physical activity amp

walking generally find a positive association

between infrastructure supportive of walking amp

physical activity

--Identifying amp creating safe routes to school

together with educational components

increased the number of students walking to

school

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Locating schools within easy walking

distance of residential areas

--Community-scale urban design amp land use policies amp

practices including locating schools stores workplaces

amp recreation areas close to residential areas are

effective in facilitating an increase in levels of physical

activity

--Majority of efforts to encourage walking to school involve

improving the routes rather than improving the location

of schools

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Improve access to public transportation

--Insufficient evidence exists to determine

effectiveness of transportation policies in

increasing the level of physical activity or

improving fitness

--1 study indicated that 29 of individuals who

walk to and from public transit achieve at least

30 minutes of daily physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Zone for mixed-use development

--Allows residential commercial institutional amp

other public land uses to be located in close

proximity to one another

--Studies using correlation analyses amp regression

models indicated that mixed land use was

associated with increased walking amp cycling

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance personal safety in areas where

persons are or could be physically active

--Cross-sectional studies have demonstrated a

negative relationship between crime rates andor

perceived safety amp physical activity in

neighborhoods

--Few intervention studies have evaluated the

impact of policies amp practices to improve

personal safety on physical activity

Geospatial Mapping Linking Urban

Environments to Health Risk

Measure association between environmental variables amp health risk factors

Assess relationships between variables at different levels of analysis

Used in conjunction with linear analyses

Our Community Environmental Model

of Obesity

Community Factors

Poverty

Crime

Grocery Quality

Restaurants

Parks

Sidewalks

Fast Food Outlets

Recreational

Facilities

Individual Factors

Dietary Intake

Physical Activity

Genetics

Family History

StressCoping

Eating Disorders

Psychological

Problems

Weight

Status

Chosen Neighborhoods

Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped

We then matched census-block groups within the income groups by population density and percentage of minority representation

One matched block group per income level was randomly selected

Prevalence of Obesity in

Block-Groups

0

5

10

15

20

25

30

35

40

45

50

Ag

e-a

dju

sted

Ob

esit

y P

rev

ale

nce

(

)

High-Income Low-Income

Age-standardized to the 1990 US Census

Density of Environmental Factors in the

Community Contributes to a ldquoToxicrdquo

Obesity Environment

0

2

4

6

8

10

12

14

16

18

Fast-food Convenience Store Bars

Den

sity

10

00

perso

ns

High-Income Low-Income

COMMUNITYrsquoS PERCEPTION OF SAFETY

0

5

10

15

20

25

30

35

40

Daytime Nighttime

Perc

en

t (

) F

eeli

ng

So

mew

hat

Safe

or

Un

safe

Low-Income High-Income

Percent Substandard (or worse) Housing

or Ground Conditions

of Residential Properties

0

10

20

30

Structural Grounds

Perc

en

t (

)

Low-Income High-Income

CONCLUSIONS

These data suggest that the higher

frequency of outlets providing

calorically-dense foods and alcohol may

contribute to greater obesity prevalence

in residents of low-income communities

More research is needed to thoroughly

document environmental determinants

of health and obesity

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

From 1994-1998 HUD randomly assigned

4498 women with children living in public

housing in high-poverty urban census

tracts to one of three groups (1) housing

vouchers redeemable only if they moved

to a low-poverty census tract (2)

unrestricted vouchers or (3) control group

(no vouchers)

Ludwig et al NEJM 201136516

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

10-12 year follow-up showed modest but

potentially important reductions in the

prevalence of extreme obesity amp diabetes in the

group moving from a neighborhood with high

poverty on one of low poverty compared to the

control group

No differences between the group receiving

traditional vouchers amp the control group

ldquoNeighborhoods matterrdquo

Ludwig et al NEJM 201136516

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance traffic safety in areas where

persons are or could be physically active

--Community-scale urban design amp land use policies to

promote physical activity including design components

to improve street lighting infrastructure projects to

increase safety of pedestrian street crossing and use of

traffic calming approaches such as speed humps amp

traffic circles are effective in increasing physical activity

--Both community-scale amp street-scale policies amp practices

are effective in increasing physical activity

Recommended Community Strategies Encourage Communities to Organize for Change

Participate in community coalitions or

partnerships to address obesity

--Little evidence is available to determine the

impact of community coalitions on obesity

prevention

--The presence of anti-smoking community

coalitions has been associated with lower rates

of tobacco consumption

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

$103 million awarded to 61 states and

communities including state amp local government

agencies tribes amp territories amp state amp local non-

profit organizations

To build capacity to implement changes for

community prevention efforts to ensure long-

term success

To implement evidence-based and practice-

based programs to improve health amp wellness

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Priority areas are

Tobacco-free living

Active living and healthy eating

Evidence-based quality clinical and other

preventive health services for prevention

and control of high blood pressure and

high cholesterol

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Applicants proposed specific activities in

line with their chosen priority areas in their

applications

Grantee activities will not be finalized until

plans are negotiated with CDC by early

2012

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Capacity-Building Award

The Confederated Tribes of The Chehalis

Reservation is receiving a $498663 planning

award to build capacity to support healthy

lifestyles among their tribal population of 1500

in Washington State

Work will target tobacco-free living active living

and healthy eating and quality clinical and other

healthy serviceswwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Implementation Award

Austin TX Dept of Health and Human Services

is receiving $1026158 to serve Travis County

(Austin) to expand efforts in tobacco-free living

active living and healthy eating quality clinical

and other preventive services social and

emotional wellness and healthy and safe

physical environmentswwwcdcgov1052011

Building sustainable healthy

communities Bottom line

Obesity is an environmental problem

Despite progress in genetic research public health advances only will occur when we take the environment seriously

Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment

Until we do this we will not make substantial progress in addressing the epidemic of obesity

Poston amp Foreyt Atherosclerosis 1999

Whatrsquos the best approach

Integrate all sectors of society into community

change interventions

Incorporate

Science amp Technology

Education

FamilyCommunity

Healthcare

Arts amp Entertainment

Law amp Politics

Commerce amp Trade

Sectors of Society

Arts amp Entertainm

ent

Commerce amp Trade

Education

FamilyCommunity

Healthcare

Law amp Politics

Science amp Technology

Project FIT rationale design and baseline characteristics of a school- and community-

based intervention to address physical activity and healthy eating among low-income

elementary school children

Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D

Oh HJ Orth J Randall S Mayfield K Holmes D

Source

Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu

Abstract

BACKGROUND

This paper describes Project FIT a collaboration between the public school system local

health systems physicians neighborhood associations businesses faith-based leaders

community agencies and university researchers to develop a multi-faceted approach to

promote physical activity and healthy eating toward the general goal of preventing and

reducing childhood obesity among children in Grand Rapids MI USA

METHODSDESIGN

There are four overall components to Project FIT school community social marketing and

school staff wellness - all that focus on 1) increasing access to safe and affordable physical

activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)

improving the affordability and availability of nutritious food in the neighborhoods surrounding

the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding

nutrition and physical activity among school staff parents and students 4) impacting the

culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging

dialogue among all community partners to leverage existing programs and introduce new

ones

2005 USDA FOOD PYRAMID

ldquoItrsquos going to be hard not to do

better than the current pyramid

which basically conveys no

useful informationrdquo

Walter C Willett MD

Chairman Department of Nutrition

Harvard School of Public Health

2011 USDA MY PLATE

ldquoWe are all

bombarded with so

many dietary

messages that it is

hard to find time to

sort through all this

informationrdquo

Michelle Obama 2011

Dietary Guidelines for Americans

2010 Two Primary Concepts

Maintain calorie balance over time to

achieve and maintain a healthy weight

Focus on consuming nutrient-dense foods

and beverages

Dietary Guidelines for Americans 2010

Efficacy-based comparative dietary guidelines

Carb Fat Pro

Mediterranean Diet 45-55 25-35 20

IOM Dietary Ref Intakes 45-65 25-35 15

NCEP-ATPIII 50-60 25-35 15

Am Dietetic Assoc 45-65 20-35 15

PARADOX OF INCREASING OBESITY

PREVALENCE

bull Focus on healthy eating and physical

activity

bull Awareness of dangers of obesity buthellip

bull Obesity prevalence continues to rise

bull Work amp commuting demands

bull Little time to exercise

bull Little time to prepare food

bull Availability of high-fatcalorie foods

Rationale for community-based interventions

bull Increases in obesity prevalence due to genes

bull Increased calories (eg 200 Kcalday

over 10 years)

bull Increased portion sizes (eg 22 oz

steaks and 44 oz sodas)

bull Western diets in developing nations

increase risk of obesity

READINESS TO CHANGE

ldquoHabit is habit and not to be

flung out of the window but

coaxed downstairs a step at a

timerdquo

Mark Twain

Long-Term Weight Maintenance

National Weight Control Registry (N=10000)

Survey of 3000 members who have been in the

Registry for at least 10 years

Starting weight = 224 lbs Average weight loss=69

lbs

At 5 years participants had maintained an average

weight loss=52 lbs

At 10 years participants had maintained an average

weight loss=51 lbs

Thomas Bond Phelan et al TOS 2011

Long-Term Weight Maintenance

Weight Maintainers report that they usually

Track their food intake

Count calories or fat grams

Follow a low-calorie low fat diet (1800 caloriesday

less than 30 of calories from fat

Eat breakfast regularly

Limit the amount they eat out (about 3 timesweek

eat fast food less than onceweek)

Thomas Bond Phelan et al TOS 2011

Long-Term Weight Maintenance

Weight Maintainers report that they usually

Eat similar food regularly

Donrsquot splurge much on holidays amp special occasions

Walk about one hourday

Watch less than 10 hours of TV a week

Weigh themselves at least once a week

Thomas Bond Phelan et al TOS 2011

LONG-TERM WEIGHT MAINTENANCE

Continued consumption of a low-

calorie diet with moderate fat intake

Limited fast food

High levels of physical activity

Phalen et al Obesity 2006 14 710-716

LONG-TERM WEIGHT MAINTENANCE

Daily weighing improved

maintenance of weight loss

particularly when delivered

face to face

Wing et al NEJM 2006 3551563-1571

Most Promising Strategies For

Preventing Weight Regain

Providing multi-component

programs with ongoing

professional contacts

Physical activityexercise

Portion controlmeal replacements

Extending treatment through

weekly or bi-weekly sessions

Pharmacotherapy

Perri Foreyt amp Anton Preventing Weight Regain After Weight Loss 2008

Most Promising Strategies For

Preventing Weight Regain

Extended treatments have shown

promise in promoting adherence to

the behaviors required for the long-

term maintenance of weight loss

Continuous care approach focused

on reasonable long-term objectives

appears appropriate for most

patients

Perri Foreyt amp Anton Preventing Weight Regain After Weight

Loss 2008

An Example of a successful long-term

intervention

The Look AHEAD Study

Does Weight Loss Reduce

Cardiovascular Disease and Death in

Overweight Individuals with Diabetes

bull Action for HEAlth in Diabetes

bull Objective to examine in overweight

persons with Type 2 Diabetes the long-

term effects of an intensive lifestyle

intervention program compared to

diabetes education and support

bull 16 Centers

bull 5145 overweight volunteers with

diabetes

Look AHEAD

Look AHEAD

Primary End Point Composite

bull Cardiovascular death (including fatal

myocardial infarction and stroke)

bull Non-fatal myocardial infarction

bull Non-fatal stroke

Winston-Salem

Baltimore

Philadelphia

New York

Providence

Boston

Clinical Site Coordinating Center

Clinical Sites

Seattle

Los Angeles

San AntonioHouston

Baton Rouge

Minneapolis

Memphis

Birmingham

Pittsburgh

Denver

Phoenix

Look AHEADParticipants

101100Baseline weight (kg)

589586Age (years)

9496Attended 1 year exam

360359Baseline BMI

1514Insulin Users

3737Minority

6059Women

(N=2574)(N=2630)

DSELifestyle

p lt 0004

Look AHEAD

Study Interventions

bull Diabetes support and education - DSE (control group)

bull Lifestyle intervention ndash ILI (treatment group)

Look AHEAD

Lifestyle Intervention

Goals

bull 7 weight loss for the group (10

for individual)

bull 175 minutes of moderate intensity

activity

Look AHEAD

Lifestyle Intervention

bull Diet

ndash ADA NCEP (lt 30 fat lt 10 sat fat

gt15 protein)

ndash 1200-1500 (if weight lt250lbs)

ndash 1500-1800 (if weight gt250lbs)

ndash During first 4 weeks to 4 months portion

control (liquid meal replacements or

structured meal plan)

Look AHEAD

Lifestyle Intervention

bull Physical Activity

ndash unsupervised

ndash 175 minutes moderate intensityweek

ndash 5 daysweek

ndash walking

Weight Loss at 1-Year

-9

ILI 0

-1

-2

-3

-4

-5

-6

-7

-8

DSE

p lt 00001

W

eig

ht

Chan

ge

86

07

The Look AHEAD Research Group Diabetes Care 2007

Reduction in Initial Weight by Gender

N=872

N=1229N=1197

N=830

-12

-10

-8

-6

-4

-2

0

0 2 4 6 8 10 12

Months

R

ed

uctio

n in

In

itia

l W

eig

ht

Men

Women

Plt0001

The Look AHEAD Research Group Diabetes Care 2007

Fitness Change () at 1-Year

0

5

10

15

20

25

Mean

Fitness C

hange

Unadjusted

Plt0001Adjusted for 1 Year

Weight Change Plt0001

58

209

108

159

DSE ILI ILIDSE

The Look AHEAD Research Group Diabetes Care 2007

1-Year Changes in Markers of

Diabetes Control

Markers of Diabetes

Control ILI DSE P-value

Hemoglobin A1c () BL

Hemoglobin A1c () Y1

Y1 ndash Baseline

725

661

-064

729

715

-014

026

lt0001

lt0001

Fasting glucose (mgdl) BL

Fasting glucose (mgdl) Y1

Y1 ndash Baseline

1519

1304

-215

1536

1464

-72

021

lt0001

lt0001

Diabetes medications BL

Diabetes medications Y1

Y1 ndash Baseline

865

786

-78

865

887

22

093

lt0001

lt0001

1-Year Changes in Markers of

Blood Pressure ControlMarkers of Blood Pressure

Control ILI DSE P-value

Systolic BP (mmHg) BL

Systolic BP (mmHg) Y1

Y1 ndash Baseline

1282

1214

-68

1294

1266

-28

026

lt0001

lt0001

Diastolic BP (mmHg) BL

Diastolic BP (mmHg) Y1

Y1 ndash Baseline

699

670

-30

704

686

-18

011

lt0001

lt0001

Antihypertensive medications BL

Antihypertensive medications Y1

Y1 ndash Baseline

753

752

-01

737

759

22

023

054

002

1-Year Changes in Markers of Lipid

Control

Markers of Lipid Control ILI DSE P-value

LDL-cholesterol (mgdl) BL

LDL-cholesterol (mgdl) Y1

Y1 ndash Baseline

1122

1070

-52

1124

1067

-57

078

074

049

HDL-cholesterol (mgdl) BL

HDL-cholesterol (mgdl) Y1

Y1 ndash Baseline

435

469

34

436

449

14

080

lt0001

lt0001

Triglycerides (mgdl) BL

Triglycerides (mgdl) Y1

Y1 ndash Baseline

1828

1525

-303

1800

1654

-146

038

lt0001

lt0001

Lipid lowering medications BL

Lipid lowering medications Y1

Y1 ndash Baseline

494

530

37

484

578

94

052

lt0001

lt0001

1-Year Changes in Percent of Participants

Meeting ADA Goals

ADA Goal ILI DSE P-value

Hemoglobin A1c lt 7 BL

Hemoglobin A1c lt 7 Y1

Y1 ndash Baseline

463

727

264

454

508

54

050

lt0001

lt0001

Blood pressure lt 13080 mmHg BL

Blood pressure lt 13080 mmHg Y1

Y1 ndash Baseline

535

686

151

499

570

70

001

lt0001

lt0001

LDL-cholesterol lt 100 mgdl BL

LDL-cholesterol lt 100 mgdl Y1

Y1 ndash Baseline

371

438

67

369

449

80

087

045

034

All three goals BL

All three goals Y1

Y1 ndash Baseline

108

236

128

95

160

65

013

lt0001

lt0001

Mean Changes in Weight Fitness amp BP

Averaged Over Four Years

DSE

Mean

ILI

Mean

P-value

Weight Loss

( initial wt)

-088 -615 lt 00001

Fitness

( METS)

196 1274 lt00001

HbA1c -009 -036 lt 00001

SBP (mm Hg) -297 -533 lt 00001

DBP (mm Hg) -248 -292 0012

Look AHEAD Research Group Arch Int Med 2010

Mean Changes in Lipid Profile

Averaged Over Four Years

DSE

Mean

ILI

Mean

P-value

HDL (mgdl) 197 367 lt00001

TG (mgdl) -1975 -2556 00006

LDL (mgdl) -1284 -1127 0009

LDL (mgdl)

(Adjusting for

medication use)

-922 -875 042

Look AHEAD Research Group Arch Int Med 2010

Percent () Completing Outcome

Measures at Years 1-4

Intervention Group

(ILI)

Year 1 971

Year 2 949

Year 3 940

Year 4 941

Comparison Group

(DSE)

Year 1 957

Year 2 935

Year 3 938

Year 4 931

Look AHEAD Summary

ILI had significantly greater improvements than DSE in all CVD risk factors averaged across 4 years (except LDL-C)

There may be long-term beneficial effects from this 4-year period in which ILI subjects have been exposed to lower CVD risk factors

Longer follow-ups will determine whether these lowered CVD risk factors can be maintained amp whether lifestyle intervention has positive effects on CVD morbidity amp mortality

Mary J

Female

White

56 years old at start of Look AHEAD

study

Past Medical History Type 2 diabetes

overweight diverticulosis arthritis

sleep apnea back pain

Mary J

bullLong term strugglesbull Helping youngest daughter with

personal issues and children

bull Rotator cuff problems

bull Degenerative disks in back

bull Rheumatoid arthritis

bull Diabetes

bull Physically demanding job

bull Financial struggles

Pounds

Years

82007 grandkids enter pre-school

Catherine L

Female

White

47 years old at start of Look AHEAD

study

Past Medical History Type 2 diabetes

overweight high blood pressure

hypothyroidism back pain

Catherine L

Long term struggles

bull Motherrsquos declining health and death

bull Multiple serious injuries

bull Sudden death of sister

bull Death of step-father

bull Declining economy

bull Children living at home

Pounds

Years

Realistic Management Goals

5-10 weight loss

Health energy and fitness

Well-being and self-esteem

Mood and appearance

Functional and recreational

activity

Key Elements

Focus on health and energy

Food and physical activity diaries

Gradual increase in physical activity

Gradual reduction in dietary fat

No feelings of food deprivation

Social support groups

Recommended Strategies for Building

Sustainable Healthy Communities

Overview from USA

Promote the availability of affordable healthy

food and beverages

Support healthy food and beverage choices

Encourage breastfeeding

Encourage physical activity or limit sedentary

activity among children amp youth

Create safe communities that support physical

activity

Encourage communities to organize for change

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Increase the availability of healthier food and

beverage choices in public service venues (eg

schools city amp county buildings etc)

--Insufficient evidence in school-based programs

--Associations suggest availability amp increased

consumption

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve availability of affordable healthier

food amp beverage choices in public service

venues

--Reducing the cost of healthier foods

increases their purchase

--Providing coupons redeemable for

healthier foods increases their purchase

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve geographic availability of

supermarkets in underserved areas

-- Greater access to nearby supermarkets is

associated with healthier eating behaviors

-- Increasing the number of supermarkets in

underserved neighborhoods increased

real estate values increased economic

activity amp employment amp resulted in lower

food prices

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Provide incentives to food retailers to locate in

andor offer healthier food choices in

underserved areas

-- Presence of retail venues that provide healthier

foods is associated with better nutrition

-- Greater availability of supermarkets was

associated with lower adolescent BMI scores

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Improve availability of mechanisms for

purchasing foods from farms

--Evidence supporting a direct link between

purchasing food from farms amp improved diet is

limited

--Two studies of initiatives to encourage

participation in farmersrsquo market showed

increased intention to eat more fruits amp

vegetables but no direct evidence

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Provide incentives for the production

distribution and procurement of foods from local

farms

--No evidence has been published to link local

food production amp health outcomes

--There is a current study exploring the potential

nutritional amp health benefits of eating locally

grown foods

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Restrict availability of less healthy foods amp

beverages in public service venues

--No peer-reviewed studies examined the impact

designed to restrict availability of less healthy

foods in public service venues

--21 states have policies that restrict the sale of

competitive foods in schools beyond USDA

regulations however no studies have evaluated

the impact of the policies

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Institute smaller portion size options in public

service venues

--Evidence is lacking to demonstrate effectiveness

of population-based interventions aimed at

reducing portion sizes in public service venues

--Evidence from clinical studies in laboratories

demonstrates decreasing portion sizes

decreases energy intake

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Limit advertisements of less healthy foods amp

beverages

--Little evidence is available regarding the impact

of restricting advertising on purchasing amp

consumption of less healthy foods

--Cross-sectional time-series studies of tobacco-

control efforts suggest an association between

advertising bans amp decreased tobacco

consumption

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Discourage consumption of sugar-sweetened

beverages

--One longitudinal study of a school-based

intervention among Native-American high school

students showed a substantial reduction in

sugar-sweetened beverages over a 3-year

period

--A RCT of a home-based intervention that

eliminated sugar-sweetened beverages showed

reduction in BMI scores

Recommended Community Strategies Strategies to encourage breastfeeding

Increase support for breastfeeding

--Evidence directly linking environmental

interventions that support breastfeeding with

obesity-related outcomes is lacking

--Epidemiologic studies indicate that breastfeeding

helps prevent pediatric obesity

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Require physical education in schools

--14 studies have demonstrated that school-based

PE was effective in increasing levels of physical

activity and improving physical fitness

--Minimum of 150 minwk in elementary schools

225 minwk in middle schools and high schools

throughout the school year as recommended by

NASPE

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Increase opportunities for extracurricular

physical activity

--Participation in after-school programs increased

studentsrsquo level of physical activity amp improved

obesity-related outcomes (improved CV fitness

reduced body fat)

--2 pilot studies providing extracurricular physical

activity showed increased levels of PA amp

decreased sedentary behavior

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Reduce screen time in public service venues

--A school-based RCT indicated that children who

reduced their television videotape amp video

game use had significant decrease in BMI tricep

skin fold thickness amp waist circumference

compared to controls

--Spending less time watching television is

associated with increased physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Improve access to outdoor recreational

facilities

--Review of 108 studies indicated that access to facilities

and programs for recreation near their homes amp time

spent outdoors correlated positively with increased

physical activity among childrenamp adults

--Perceptions that footpaths are safe for walking was

significantly associated with adults being classified as

physically active at a level sufficient for health benefits

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting

bicycling

--Longitudinal intervention studies have

demonstrated that improving bicycling

infrastructure is associated with increased

frequency of bicycling

--Cross-sectional studies indicated a significant

association between bicycling infrastructure amp

frequency of biking

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting walking

--Reviews of cross-sectional studies of

environmental correlates of physical activity amp

walking generally find a positive association

between infrastructure supportive of walking amp

physical activity

--Identifying amp creating safe routes to school

together with educational components

increased the number of students walking to

school

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Locating schools within easy walking

distance of residential areas

--Community-scale urban design amp land use policies amp

practices including locating schools stores workplaces

amp recreation areas close to residential areas are

effective in facilitating an increase in levels of physical

activity

--Majority of efforts to encourage walking to school involve

improving the routes rather than improving the location

of schools

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Improve access to public transportation

--Insufficient evidence exists to determine

effectiveness of transportation policies in

increasing the level of physical activity or

improving fitness

--1 study indicated that 29 of individuals who

walk to and from public transit achieve at least

30 minutes of daily physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Zone for mixed-use development

--Allows residential commercial institutional amp

other public land uses to be located in close

proximity to one another

--Studies using correlation analyses amp regression

models indicated that mixed land use was

associated with increased walking amp cycling

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance personal safety in areas where

persons are or could be physically active

--Cross-sectional studies have demonstrated a

negative relationship between crime rates andor

perceived safety amp physical activity in

neighborhoods

--Few intervention studies have evaluated the

impact of policies amp practices to improve

personal safety on physical activity

Geospatial Mapping Linking Urban

Environments to Health Risk

Measure association between environmental variables amp health risk factors

Assess relationships between variables at different levels of analysis

Used in conjunction with linear analyses

Our Community Environmental Model

of Obesity

Community Factors

Poverty

Crime

Grocery Quality

Restaurants

Parks

Sidewalks

Fast Food Outlets

Recreational

Facilities

Individual Factors

Dietary Intake

Physical Activity

Genetics

Family History

StressCoping

Eating Disorders

Psychological

Problems

Weight

Status

Chosen Neighborhoods

Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped

We then matched census-block groups within the income groups by population density and percentage of minority representation

One matched block group per income level was randomly selected

Prevalence of Obesity in

Block-Groups

0

5

10

15

20

25

30

35

40

45

50

Ag

e-a

dju

sted

Ob

esit

y P

rev

ale

nce

(

)

High-Income Low-Income

Age-standardized to the 1990 US Census

Density of Environmental Factors in the

Community Contributes to a ldquoToxicrdquo

Obesity Environment

0

2

4

6

8

10

12

14

16

18

Fast-food Convenience Store Bars

Den

sity

10

00

perso

ns

High-Income Low-Income

COMMUNITYrsquoS PERCEPTION OF SAFETY

0

5

10

15

20

25

30

35

40

Daytime Nighttime

Perc

en

t (

) F

eeli

ng

So

mew

hat

Safe

or

Un

safe

Low-Income High-Income

Percent Substandard (or worse) Housing

or Ground Conditions

of Residential Properties

0

10

20

30

Structural Grounds

Perc

en

t (

)

Low-Income High-Income

CONCLUSIONS

These data suggest that the higher

frequency of outlets providing

calorically-dense foods and alcohol may

contribute to greater obesity prevalence

in residents of low-income communities

More research is needed to thoroughly

document environmental determinants

of health and obesity

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

From 1994-1998 HUD randomly assigned

4498 women with children living in public

housing in high-poverty urban census

tracts to one of three groups (1) housing

vouchers redeemable only if they moved

to a low-poverty census tract (2)

unrestricted vouchers or (3) control group

(no vouchers)

Ludwig et al NEJM 201136516

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

10-12 year follow-up showed modest but

potentially important reductions in the

prevalence of extreme obesity amp diabetes in the

group moving from a neighborhood with high

poverty on one of low poverty compared to the

control group

No differences between the group receiving

traditional vouchers amp the control group

ldquoNeighborhoods matterrdquo

Ludwig et al NEJM 201136516

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance traffic safety in areas where

persons are or could be physically active

--Community-scale urban design amp land use policies to

promote physical activity including design components

to improve street lighting infrastructure projects to

increase safety of pedestrian street crossing and use of

traffic calming approaches such as speed humps amp

traffic circles are effective in increasing physical activity

--Both community-scale amp street-scale policies amp practices

are effective in increasing physical activity

Recommended Community Strategies Encourage Communities to Organize for Change

Participate in community coalitions or

partnerships to address obesity

--Little evidence is available to determine the

impact of community coalitions on obesity

prevention

--The presence of anti-smoking community

coalitions has been associated with lower rates

of tobacco consumption

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

$103 million awarded to 61 states and

communities including state amp local government

agencies tribes amp territories amp state amp local non-

profit organizations

To build capacity to implement changes for

community prevention efforts to ensure long-

term success

To implement evidence-based and practice-

based programs to improve health amp wellness

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Priority areas are

Tobacco-free living

Active living and healthy eating

Evidence-based quality clinical and other

preventive health services for prevention

and control of high blood pressure and

high cholesterol

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Applicants proposed specific activities in

line with their chosen priority areas in their

applications

Grantee activities will not be finalized until

plans are negotiated with CDC by early

2012

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Capacity-Building Award

The Confederated Tribes of The Chehalis

Reservation is receiving a $498663 planning

award to build capacity to support healthy

lifestyles among their tribal population of 1500

in Washington State

Work will target tobacco-free living active living

and healthy eating and quality clinical and other

healthy serviceswwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Implementation Award

Austin TX Dept of Health and Human Services

is receiving $1026158 to serve Travis County

(Austin) to expand efforts in tobacco-free living

active living and healthy eating quality clinical

and other preventive services social and

emotional wellness and healthy and safe

physical environmentswwwcdcgov1052011

Building sustainable healthy

communities Bottom line

Obesity is an environmental problem

Despite progress in genetic research public health advances only will occur when we take the environment seriously

Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment

Until we do this we will not make substantial progress in addressing the epidemic of obesity

Poston amp Foreyt Atherosclerosis 1999

Whatrsquos the best approach

Integrate all sectors of society into community

change interventions

Incorporate

Science amp Technology

Education

FamilyCommunity

Healthcare

Arts amp Entertainment

Law amp Politics

Commerce amp Trade

Sectors of Society

Arts amp Entertainm

ent

Commerce amp Trade

Education

FamilyCommunity

Healthcare

Law amp Politics

Science amp Technology

Project FIT rationale design and baseline characteristics of a school- and community-

based intervention to address physical activity and healthy eating among low-income

elementary school children

Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D

Oh HJ Orth J Randall S Mayfield K Holmes D

Source

Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu

Abstract

BACKGROUND

This paper describes Project FIT a collaboration between the public school system local

health systems physicians neighborhood associations businesses faith-based leaders

community agencies and university researchers to develop a multi-faceted approach to

promote physical activity and healthy eating toward the general goal of preventing and

reducing childhood obesity among children in Grand Rapids MI USA

METHODSDESIGN

There are four overall components to Project FIT school community social marketing and

school staff wellness - all that focus on 1) increasing access to safe and affordable physical

activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)

improving the affordability and availability of nutritious food in the neighborhoods surrounding

the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding

nutrition and physical activity among school staff parents and students 4) impacting the

culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging

dialogue among all community partners to leverage existing programs and introduce new

ones

2011 USDA MY PLATE

ldquoWe are all

bombarded with so

many dietary

messages that it is

hard to find time to

sort through all this

informationrdquo

Michelle Obama 2011

Dietary Guidelines for Americans

2010 Two Primary Concepts

Maintain calorie balance over time to

achieve and maintain a healthy weight

Focus on consuming nutrient-dense foods

and beverages

Dietary Guidelines for Americans 2010

Efficacy-based comparative dietary guidelines

Carb Fat Pro

Mediterranean Diet 45-55 25-35 20

IOM Dietary Ref Intakes 45-65 25-35 15

NCEP-ATPIII 50-60 25-35 15

Am Dietetic Assoc 45-65 20-35 15

PARADOX OF INCREASING OBESITY

PREVALENCE

bull Focus on healthy eating and physical

activity

bull Awareness of dangers of obesity buthellip

bull Obesity prevalence continues to rise

bull Work amp commuting demands

bull Little time to exercise

bull Little time to prepare food

bull Availability of high-fatcalorie foods

Rationale for community-based interventions

bull Increases in obesity prevalence due to genes

bull Increased calories (eg 200 Kcalday

over 10 years)

bull Increased portion sizes (eg 22 oz

steaks and 44 oz sodas)

bull Western diets in developing nations

increase risk of obesity

READINESS TO CHANGE

ldquoHabit is habit and not to be

flung out of the window but

coaxed downstairs a step at a

timerdquo

Mark Twain

Long-Term Weight Maintenance

National Weight Control Registry (N=10000)

Survey of 3000 members who have been in the

Registry for at least 10 years

Starting weight = 224 lbs Average weight loss=69

lbs

At 5 years participants had maintained an average

weight loss=52 lbs

At 10 years participants had maintained an average

weight loss=51 lbs

Thomas Bond Phelan et al TOS 2011

Long-Term Weight Maintenance

Weight Maintainers report that they usually

Track their food intake

Count calories or fat grams

Follow a low-calorie low fat diet (1800 caloriesday

less than 30 of calories from fat

Eat breakfast regularly

Limit the amount they eat out (about 3 timesweek

eat fast food less than onceweek)

Thomas Bond Phelan et al TOS 2011

Long-Term Weight Maintenance

Weight Maintainers report that they usually

Eat similar food regularly

Donrsquot splurge much on holidays amp special occasions

Walk about one hourday

Watch less than 10 hours of TV a week

Weigh themselves at least once a week

Thomas Bond Phelan et al TOS 2011

LONG-TERM WEIGHT MAINTENANCE

Continued consumption of a low-

calorie diet with moderate fat intake

Limited fast food

High levels of physical activity

Phalen et al Obesity 2006 14 710-716

LONG-TERM WEIGHT MAINTENANCE

Daily weighing improved

maintenance of weight loss

particularly when delivered

face to face

Wing et al NEJM 2006 3551563-1571

Most Promising Strategies For

Preventing Weight Regain

Providing multi-component

programs with ongoing

professional contacts

Physical activityexercise

Portion controlmeal replacements

Extending treatment through

weekly or bi-weekly sessions

Pharmacotherapy

Perri Foreyt amp Anton Preventing Weight Regain After Weight Loss 2008

Most Promising Strategies For

Preventing Weight Regain

Extended treatments have shown

promise in promoting adherence to

the behaviors required for the long-

term maintenance of weight loss

Continuous care approach focused

on reasonable long-term objectives

appears appropriate for most

patients

Perri Foreyt amp Anton Preventing Weight Regain After Weight

Loss 2008

An Example of a successful long-term

intervention

The Look AHEAD Study

Does Weight Loss Reduce

Cardiovascular Disease and Death in

Overweight Individuals with Diabetes

bull Action for HEAlth in Diabetes

bull Objective to examine in overweight

persons with Type 2 Diabetes the long-

term effects of an intensive lifestyle

intervention program compared to

diabetes education and support

bull 16 Centers

bull 5145 overweight volunteers with

diabetes

Look AHEAD

Look AHEAD

Primary End Point Composite

bull Cardiovascular death (including fatal

myocardial infarction and stroke)

bull Non-fatal myocardial infarction

bull Non-fatal stroke

Winston-Salem

Baltimore

Philadelphia

New York

Providence

Boston

Clinical Site Coordinating Center

Clinical Sites

Seattle

Los Angeles

San AntonioHouston

Baton Rouge

Minneapolis

Memphis

Birmingham

Pittsburgh

Denver

Phoenix

Look AHEADParticipants

101100Baseline weight (kg)

589586Age (years)

9496Attended 1 year exam

360359Baseline BMI

1514Insulin Users

3737Minority

6059Women

(N=2574)(N=2630)

DSELifestyle

p lt 0004

Look AHEAD

Study Interventions

bull Diabetes support and education - DSE (control group)

bull Lifestyle intervention ndash ILI (treatment group)

Look AHEAD

Lifestyle Intervention

Goals

bull 7 weight loss for the group (10

for individual)

bull 175 minutes of moderate intensity

activity

Look AHEAD

Lifestyle Intervention

bull Diet

ndash ADA NCEP (lt 30 fat lt 10 sat fat

gt15 protein)

ndash 1200-1500 (if weight lt250lbs)

ndash 1500-1800 (if weight gt250lbs)

ndash During first 4 weeks to 4 months portion

control (liquid meal replacements or

structured meal plan)

Look AHEAD

Lifestyle Intervention

bull Physical Activity

ndash unsupervised

ndash 175 minutes moderate intensityweek

ndash 5 daysweek

ndash walking

Weight Loss at 1-Year

-9

ILI 0

-1

-2

-3

-4

-5

-6

-7

-8

DSE

p lt 00001

W

eig

ht

Chan

ge

86

07

The Look AHEAD Research Group Diabetes Care 2007

Reduction in Initial Weight by Gender

N=872

N=1229N=1197

N=830

-12

-10

-8

-6

-4

-2

0

0 2 4 6 8 10 12

Months

R

ed

uctio

n in

In

itia

l W

eig

ht

Men

Women

Plt0001

The Look AHEAD Research Group Diabetes Care 2007

Fitness Change () at 1-Year

0

5

10

15

20

25

Mean

Fitness C

hange

Unadjusted

Plt0001Adjusted for 1 Year

Weight Change Plt0001

58

209

108

159

DSE ILI ILIDSE

The Look AHEAD Research Group Diabetes Care 2007

1-Year Changes in Markers of

Diabetes Control

Markers of Diabetes

Control ILI DSE P-value

Hemoglobin A1c () BL

Hemoglobin A1c () Y1

Y1 ndash Baseline

725

661

-064

729

715

-014

026

lt0001

lt0001

Fasting glucose (mgdl) BL

Fasting glucose (mgdl) Y1

Y1 ndash Baseline

1519

1304

-215

1536

1464

-72

021

lt0001

lt0001

Diabetes medications BL

Diabetes medications Y1

Y1 ndash Baseline

865

786

-78

865

887

22

093

lt0001

lt0001

1-Year Changes in Markers of

Blood Pressure ControlMarkers of Blood Pressure

Control ILI DSE P-value

Systolic BP (mmHg) BL

Systolic BP (mmHg) Y1

Y1 ndash Baseline

1282

1214

-68

1294

1266

-28

026

lt0001

lt0001

Diastolic BP (mmHg) BL

Diastolic BP (mmHg) Y1

Y1 ndash Baseline

699

670

-30

704

686

-18

011

lt0001

lt0001

Antihypertensive medications BL

Antihypertensive medications Y1

Y1 ndash Baseline

753

752

-01

737

759

22

023

054

002

1-Year Changes in Markers of Lipid

Control

Markers of Lipid Control ILI DSE P-value

LDL-cholesterol (mgdl) BL

LDL-cholesterol (mgdl) Y1

Y1 ndash Baseline

1122

1070

-52

1124

1067

-57

078

074

049

HDL-cholesterol (mgdl) BL

HDL-cholesterol (mgdl) Y1

Y1 ndash Baseline

435

469

34

436

449

14

080

lt0001

lt0001

Triglycerides (mgdl) BL

Triglycerides (mgdl) Y1

Y1 ndash Baseline

1828

1525

-303

1800

1654

-146

038

lt0001

lt0001

Lipid lowering medications BL

Lipid lowering medications Y1

Y1 ndash Baseline

494

530

37

484

578

94

052

lt0001

lt0001

1-Year Changes in Percent of Participants

Meeting ADA Goals

ADA Goal ILI DSE P-value

Hemoglobin A1c lt 7 BL

Hemoglobin A1c lt 7 Y1

Y1 ndash Baseline

463

727

264

454

508

54

050

lt0001

lt0001

Blood pressure lt 13080 mmHg BL

Blood pressure lt 13080 mmHg Y1

Y1 ndash Baseline

535

686

151

499

570

70

001

lt0001

lt0001

LDL-cholesterol lt 100 mgdl BL

LDL-cholesterol lt 100 mgdl Y1

Y1 ndash Baseline

371

438

67

369

449

80

087

045

034

All three goals BL

All three goals Y1

Y1 ndash Baseline

108

236

128

95

160

65

013

lt0001

lt0001

Mean Changes in Weight Fitness amp BP

Averaged Over Four Years

DSE

Mean

ILI

Mean

P-value

Weight Loss

( initial wt)

-088 -615 lt 00001

Fitness

( METS)

196 1274 lt00001

HbA1c -009 -036 lt 00001

SBP (mm Hg) -297 -533 lt 00001

DBP (mm Hg) -248 -292 0012

Look AHEAD Research Group Arch Int Med 2010

Mean Changes in Lipid Profile

Averaged Over Four Years

DSE

Mean

ILI

Mean

P-value

HDL (mgdl) 197 367 lt00001

TG (mgdl) -1975 -2556 00006

LDL (mgdl) -1284 -1127 0009

LDL (mgdl)

(Adjusting for

medication use)

-922 -875 042

Look AHEAD Research Group Arch Int Med 2010

Percent () Completing Outcome

Measures at Years 1-4

Intervention Group

(ILI)

Year 1 971

Year 2 949

Year 3 940

Year 4 941

Comparison Group

(DSE)

Year 1 957

Year 2 935

Year 3 938

Year 4 931

Look AHEAD Summary

ILI had significantly greater improvements than DSE in all CVD risk factors averaged across 4 years (except LDL-C)

There may be long-term beneficial effects from this 4-year period in which ILI subjects have been exposed to lower CVD risk factors

Longer follow-ups will determine whether these lowered CVD risk factors can be maintained amp whether lifestyle intervention has positive effects on CVD morbidity amp mortality

Mary J

Female

White

56 years old at start of Look AHEAD

study

Past Medical History Type 2 diabetes

overweight diverticulosis arthritis

sleep apnea back pain

Mary J

bullLong term strugglesbull Helping youngest daughter with

personal issues and children

bull Rotator cuff problems

bull Degenerative disks in back

bull Rheumatoid arthritis

bull Diabetes

bull Physically demanding job

bull Financial struggles

Pounds

Years

82007 grandkids enter pre-school

Catherine L

Female

White

47 years old at start of Look AHEAD

study

Past Medical History Type 2 diabetes

overweight high blood pressure

hypothyroidism back pain

Catherine L

Long term struggles

bull Motherrsquos declining health and death

bull Multiple serious injuries

bull Sudden death of sister

bull Death of step-father

bull Declining economy

bull Children living at home

Pounds

Years

Realistic Management Goals

5-10 weight loss

Health energy and fitness

Well-being and self-esteem

Mood and appearance

Functional and recreational

activity

Key Elements

Focus on health and energy

Food and physical activity diaries

Gradual increase in physical activity

Gradual reduction in dietary fat

No feelings of food deprivation

Social support groups

Recommended Strategies for Building

Sustainable Healthy Communities

Overview from USA

Promote the availability of affordable healthy

food and beverages

Support healthy food and beverage choices

Encourage breastfeeding

Encourage physical activity or limit sedentary

activity among children amp youth

Create safe communities that support physical

activity

Encourage communities to organize for change

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Increase the availability of healthier food and

beverage choices in public service venues (eg

schools city amp county buildings etc)

--Insufficient evidence in school-based programs

--Associations suggest availability amp increased

consumption

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve availability of affordable healthier

food amp beverage choices in public service

venues

--Reducing the cost of healthier foods

increases their purchase

--Providing coupons redeemable for

healthier foods increases their purchase

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve geographic availability of

supermarkets in underserved areas

-- Greater access to nearby supermarkets is

associated with healthier eating behaviors

-- Increasing the number of supermarkets in

underserved neighborhoods increased

real estate values increased economic

activity amp employment amp resulted in lower

food prices

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Provide incentives to food retailers to locate in

andor offer healthier food choices in

underserved areas

-- Presence of retail venues that provide healthier

foods is associated with better nutrition

-- Greater availability of supermarkets was

associated with lower adolescent BMI scores

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Improve availability of mechanisms for

purchasing foods from farms

--Evidence supporting a direct link between

purchasing food from farms amp improved diet is

limited

--Two studies of initiatives to encourage

participation in farmersrsquo market showed

increased intention to eat more fruits amp

vegetables but no direct evidence

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Provide incentives for the production

distribution and procurement of foods from local

farms

--No evidence has been published to link local

food production amp health outcomes

--There is a current study exploring the potential

nutritional amp health benefits of eating locally

grown foods

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Restrict availability of less healthy foods amp

beverages in public service venues

--No peer-reviewed studies examined the impact

designed to restrict availability of less healthy

foods in public service venues

--21 states have policies that restrict the sale of

competitive foods in schools beyond USDA

regulations however no studies have evaluated

the impact of the policies

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Institute smaller portion size options in public

service venues

--Evidence is lacking to demonstrate effectiveness

of population-based interventions aimed at

reducing portion sizes in public service venues

--Evidence from clinical studies in laboratories

demonstrates decreasing portion sizes

decreases energy intake

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Limit advertisements of less healthy foods amp

beverages

--Little evidence is available regarding the impact

of restricting advertising on purchasing amp

consumption of less healthy foods

--Cross-sectional time-series studies of tobacco-

control efforts suggest an association between

advertising bans amp decreased tobacco

consumption

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Discourage consumption of sugar-sweetened

beverages

--One longitudinal study of a school-based

intervention among Native-American high school

students showed a substantial reduction in

sugar-sweetened beverages over a 3-year

period

--A RCT of a home-based intervention that

eliminated sugar-sweetened beverages showed

reduction in BMI scores

Recommended Community Strategies Strategies to encourage breastfeeding

Increase support for breastfeeding

--Evidence directly linking environmental

interventions that support breastfeeding with

obesity-related outcomes is lacking

--Epidemiologic studies indicate that breastfeeding

helps prevent pediatric obesity

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Require physical education in schools

--14 studies have demonstrated that school-based

PE was effective in increasing levels of physical

activity and improving physical fitness

--Minimum of 150 minwk in elementary schools

225 minwk in middle schools and high schools

throughout the school year as recommended by

NASPE

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Increase opportunities for extracurricular

physical activity

--Participation in after-school programs increased

studentsrsquo level of physical activity amp improved

obesity-related outcomes (improved CV fitness

reduced body fat)

--2 pilot studies providing extracurricular physical

activity showed increased levels of PA amp

decreased sedentary behavior

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Reduce screen time in public service venues

--A school-based RCT indicated that children who

reduced their television videotape amp video

game use had significant decrease in BMI tricep

skin fold thickness amp waist circumference

compared to controls

--Spending less time watching television is

associated with increased physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Improve access to outdoor recreational

facilities

--Review of 108 studies indicated that access to facilities

and programs for recreation near their homes amp time

spent outdoors correlated positively with increased

physical activity among childrenamp adults

--Perceptions that footpaths are safe for walking was

significantly associated with adults being classified as

physically active at a level sufficient for health benefits

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting

bicycling

--Longitudinal intervention studies have

demonstrated that improving bicycling

infrastructure is associated with increased

frequency of bicycling

--Cross-sectional studies indicated a significant

association between bicycling infrastructure amp

frequency of biking

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting walking

--Reviews of cross-sectional studies of

environmental correlates of physical activity amp

walking generally find a positive association

between infrastructure supportive of walking amp

physical activity

--Identifying amp creating safe routes to school

together with educational components

increased the number of students walking to

school

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Locating schools within easy walking

distance of residential areas

--Community-scale urban design amp land use policies amp

practices including locating schools stores workplaces

amp recreation areas close to residential areas are

effective in facilitating an increase in levels of physical

activity

--Majority of efforts to encourage walking to school involve

improving the routes rather than improving the location

of schools

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Improve access to public transportation

--Insufficient evidence exists to determine

effectiveness of transportation policies in

increasing the level of physical activity or

improving fitness

--1 study indicated that 29 of individuals who

walk to and from public transit achieve at least

30 minutes of daily physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Zone for mixed-use development

--Allows residential commercial institutional amp

other public land uses to be located in close

proximity to one another

--Studies using correlation analyses amp regression

models indicated that mixed land use was

associated with increased walking amp cycling

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance personal safety in areas where

persons are or could be physically active

--Cross-sectional studies have demonstrated a

negative relationship between crime rates andor

perceived safety amp physical activity in

neighborhoods

--Few intervention studies have evaluated the

impact of policies amp practices to improve

personal safety on physical activity

Geospatial Mapping Linking Urban

Environments to Health Risk

Measure association between environmental variables amp health risk factors

Assess relationships between variables at different levels of analysis

Used in conjunction with linear analyses

Our Community Environmental Model

of Obesity

Community Factors

Poverty

Crime

Grocery Quality

Restaurants

Parks

Sidewalks

Fast Food Outlets

Recreational

Facilities

Individual Factors

Dietary Intake

Physical Activity

Genetics

Family History

StressCoping

Eating Disorders

Psychological

Problems

Weight

Status

Chosen Neighborhoods

Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped

We then matched census-block groups within the income groups by population density and percentage of minority representation

One matched block group per income level was randomly selected

Prevalence of Obesity in

Block-Groups

0

5

10

15

20

25

30

35

40

45

50

Ag

e-a

dju

sted

Ob

esit

y P

rev

ale

nce

(

)

High-Income Low-Income

Age-standardized to the 1990 US Census

Density of Environmental Factors in the

Community Contributes to a ldquoToxicrdquo

Obesity Environment

0

2

4

6

8

10

12

14

16

18

Fast-food Convenience Store Bars

Den

sity

10

00

perso

ns

High-Income Low-Income

COMMUNITYrsquoS PERCEPTION OF SAFETY

0

5

10

15

20

25

30

35

40

Daytime Nighttime

Perc

en

t (

) F

eeli

ng

So

mew

hat

Safe

or

Un

safe

Low-Income High-Income

Percent Substandard (or worse) Housing

or Ground Conditions

of Residential Properties

0

10

20

30

Structural Grounds

Perc

en

t (

)

Low-Income High-Income

CONCLUSIONS

These data suggest that the higher

frequency of outlets providing

calorically-dense foods and alcohol may

contribute to greater obesity prevalence

in residents of low-income communities

More research is needed to thoroughly

document environmental determinants

of health and obesity

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

From 1994-1998 HUD randomly assigned

4498 women with children living in public

housing in high-poverty urban census

tracts to one of three groups (1) housing

vouchers redeemable only if they moved

to a low-poverty census tract (2)

unrestricted vouchers or (3) control group

(no vouchers)

Ludwig et al NEJM 201136516

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

10-12 year follow-up showed modest but

potentially important reductions in the

prevalence of extreme obesity amp diabetes in the

group moving from a neighborhood with high

poverty on one of low poverty compared to the

control group

No differences between the group receiving

traditional vouchers amp the control group

ldquoNeighborhoods matterrdquo

Ludwig et al NEJM 201136516

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance traffic safety in areas where

persons are or could be physically active

--Community-scale urban design amp land use policies to

promote physical activity including design components

to improve street lighting infrastructure projects to

increase safety of pedestrian street crossing and use of

traffic calming approaches such as speed humps amp

traffic circles are effective in increasing physical activity

--Both community-scale amp street-scale policies amp practices

are effective in increasing physical activity

Recommended Community Strategies Encourage Communities to Organize for Change

Participate in community coalitions or

partnerships to address obesity

--Little evidence is available to determine the

impact of community coalitions on obesity

prevention

--The presence of anti-smoking community

coalitions has been associated with lower rates

of tobacco consumption

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

$103 million awarded to 61 states and

communities including state amp local government

agencies tribes amp territories amp state amp local non-

profit organizations

To build capacity to implement changes for

community prevention efforts to ensure long-

term success

To implement evidence-based and practice-

based programs to improve health amp wellness

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Priority areas are

Tobacco-free living

Active living and healthy eating

Evidence-based quality clinical and other

preventive health services for prevention

and control of high blood pressure and

high cholesterol

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Applicants proposed specific activities in

line with their chosen priority areas in their

applications

Grantee activities will not be finalized until

plans are negotiated with CDC by early

2012

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Capacity-Building Award

The Confederated Tribes of The Chehalis

Reservation is receiving a $498663 planning

award to build capacity to support healthy

lifestyles among their tribal population of 1500

in Washington State

Work will target tobacco-free living active living

and healthy eating and quality clinical and other

healthy serviceswwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Implementation Award

Austin TX Dept of Health and Human Services

is receiving $1026158 to serve Travis County

(Austin) to expand efforts in tobacco-free living

active living and healthy eating quality clinical

and other preventive services social and

emotional wellness and healthy and safe

physical environmentswwwcdcgov1052011

Building sustainable healthy

communities Bottom line

Obesity is an environmental problem

Despite progress in genetic research public health advances only will occur when we take the environment seriously

Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment

Until we do this we will not make substantial progress in addressing the epidemic of obesity

Poston amp Foreyt Atherosclerosis 1999

Whatrsquos the best approach

Integrate all sectors of society into community

change interventions

Incorporate

Science amp Technology

Education

FamilyCommunity

Healthcare

Arts amp Entertainment

Law amp Politics

Commerce amp Trade

Sectors of Society

Arts amp Entertainm

ent

Commerce amp Trade

Education

FamilyCommunity

Healthcare

Law amp Politics

Science amp Technology

Project FIT rationale design and baseline characteristics of a school- and community-

based intervention to address physical activity and healthy eating among low-income

elementary school children

Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D

Oh HJ Orth J Randall S Mayfield K Holmes D

Source

Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu

Abstract

BACKGROUND

This paper describes Project FIT a collaboration between the public school system local

health systems physicians neighborhood associations businesses faith-based leaders

community agencies and university researchers to develop a multi-faceted approach to

promote physical activity and healthy eating toward the general goal of preventing and

reducing childhood obesity among children in Grand Rapids MI USA

METHODSDESIGN

There are four overall components to Project FIT school community social marketing and

school staff wellness - all that focus on 1) increasing access to safe and affordable physical

activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)

improving the affordability and availability of nutritious food in the neighborhoods surrounding

the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding

nutrition and physical activity among school staff parents and students 4) impacting the

culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging

dialogue among all community partners to leverage existing programs and introduce new

ones

Dietary Guidelines for Americans

2010 Two Primary Concepts

Maintain calorie balance over time to

achieve and maintain a healthy weight

Focus on consuming nutrient-dense foods

and beverages

Dietary Guidelines for Americans 2010

Efficacy-based comparative dietary guidelines

Carb Fat Pro

Mediterranean Diet 45-55 25-35 20

IOM Dietary Ref Intakes 45-65 25-35 15

NCEP-ATPIII 50-60 25-35 15

Am Dietetic Assoc 45-65 20-35 15

PARADOX OF INCREASING OBESITY

PREVALENCE

bull Focus on healthy eating and physical

activity

bull Awareness of dangers of obesity buthellip

bull Obesity prevalence continues to rise

bull Work amp commuting demands

bull Little time to exercise

bull Little time to prepare food

bull Availability of high-fatcalorie foods

Rationale for community-based interventions

bull Increases in obesity prevalence due to genes

bull Increased calories (eg 200 Kcalday

over 10 years)

bull Increased portion sizes (eg 22 oz

steaks and 44 oz sodas)

bull Western diets in developing nations

increase risk of obesity

READINESS TO CHANGE

ldquoHabit is habit and not to be

flung out of the window but

coaxed downstairs a step at a

timerdquo

Mark Twain

Long-Term Weight Maintenance

National Weight Control Registry (N=10000)

Survey of 3000 members who have been in the

Registry for at least 10 years

Starting weight = 224 lbs Average weight loss=69

lbs

At 5 years participants had maintained an average

weight loss=52 lbs

At 10 years participants had maintained an average

weight loss=51 lbs

Thomas Bond Phelan et al TOS 2011

Long-Term Weight Maintenance

Weight Maintainers report that they usually

Track their food intake

Count calories or fat grams

Follow a low-calorie low fat diet (1800 caloriesday

less than 30 of calories from fat

Eat breakfast regularly

Limit the amount they eat out (about 3 timesweek

eat fast food less than onceweek)

Thomas Bond Phelan et al TOS 2011

Long-Term Weight Maintenance

Weight Maintainers report that they usually

Eat similar food regularly

Donrsquot splurge much on holidays amp special occasions

Walk about one hourday

Watch less than 10 hours of TV a week

Weigh themselves at least once a week

Thomas Bond Phelan et al TOS 2011

LONG-TERM WEIGHT MAINTENANCE

Continued consumption of a low-

calorie diet with moderate fat intake

Limited fast food

High levels of physical activity

Phalen et al Obesity 2006 14 710-716

LONG-TERM WEIGHT MAINTENANCE

Daily weighing improved

maintenance of weight loss

particularly when delivered

face to face

Wing et al NEJM 2006 3551563-1571

Most Promising Strategies For

Preventing Weight Regain

Providing multi-component

programs with ongoing

professional contacts

Physical activityexercise

Portion controlmeal replacements

Extending treatment through

weekly or bi-weekly sessions

Pharmacotherapy

Perri Foreyt amp Anton Preventing Weight Regain After Weight Loss 2008

Most Promising Strategies For

Preventing Weight Regain

Extended treatments have shown

promise in promoting adherence to

the behaviors required for the long-

term maintenance of weight loss

Continuous care approach focused

on reasonable long-term objectives

appears appropriate for most

patients

Perri Foreyt amp Anton Preventing Weight Regain After Weight

Loss 2008

An Example of a successful long-term

intervention

The Look AHEAD Study

Does Weight Loss Reduce

Cardiovascular Disease and Death in

Overweight Individuals with Diabetes

bull Action for HEAlth in Diabetes

bull Objective to examine in overweight

persons with Type 2 Diabetes the long-

term effects of an intensive lifestyle

intervention program compared to

diabetes education and support

bull 16 Centers

bull 5145 overweight volunteers with

diabetes

Look AHEAD

Look AHEAD

Primary End Point Composite

bull Cardiovascular death (including fatal

myocardial infarction and stroke)

bull Non-fatal myocardial infarction

bull Non-fatal stroke

Winston-Salem

Baltimore

Philadelphia

New York

Providence

Boston

Clinical Site Coordinating Center

Clinical Sites

Seattle

Los Angeles

San AntonioHouston

Baton Rouge

Minneapolis

Memphis

Birmingham

Pittsburgh

Denver

Phoenix

Look AHEADParticipants

101100Baseline weight (kg)

589586Age (years)

9496Attended 1 year exam

360359Baseline BMI

1514Insulin Users

3737Minority

6059Women

(N=2574)(N=2630)

DSELifestyle

p lt 0004

Look AHEAD

Study Interventions

bull Diabetes support and education - DSE (control group)

bull Lifestyle intervention ndash ILI (treatment group)

Look AHEAD

Lifestyle Intervention

Goals

bull 7 weight loss for the group (10

for individual)

bull 175 minutes of moderate intensity

activity

Look AHEAD

Lifestyle Intervention

bull Diet

ndash ADA NCEP (lt 30 fat lt 10 sat fat

gt15 protein)

ndash 1200-1500 (if weight lt250lbs)

ndash 1500-1800 (if weight gt250lbs)

ndash During first 4 weeks to 4 months portion

control (liquid meal replacements or

structured meal plan)

Look AHEAD

Lifestyle Intervention

bull Physical Activity

ndash unsupervised

ndash 175 minutes moderate intensityweek

ndash 5 daysweek

ndash walking

Weight Loss at 1-Year

-9

ILI 0

-1

-2

-3

-4

-5

-6

-7

-8

DSE

p lt 00001

W

eig

ht

Chan

ge

86

07

The Look AHEAD Research Group Diabetes Care 2007

Reduction in Initial Weight by Gender

N=872

N=1229N=1197

N=830

-12

-10

-8

-6

-4

-2

0

0 2 4 6 8 10 12

Months

R

ed

uctio

n in

In

itia

l W

eig

ht

Men

Women

Plt0001

The Look AHEAD Research Group Diabetes Care 2007

Fitness Change () at 1-Year

0

5

10

15

20

25

Mean

Fitness C

hange

Unadjusted

Plt0001Adjusted for 1 Year

Weight Change Plt0001

58

209

108

159

DSE ILI ILIDSE

The Look AHEAD Research Group Diabetes Care 2007

1-Year Changes in Markers of

Diabetes Control

Markers of Diabetes

Control ILI DSE P-value

Hemoglobin A1c () BL

Hemoglobin A1c () Y1

Y1 ndash Baseline

725

661

-064

729

715

-014

026

lt0001

lt0001

Fasting glucose (mgdl) BL

Fasting glucose (mgdl) Y1

Y1 ndash Baseline

1519

1304

-215

1536

1464

-72

021

lt0001

lt0001

Diabetes medications BL

Diabetes medications Y1

Y1 ndash Baseline

865

786

-78

865

887

22

093

lt0001

lt0001

1-Year Changes in Markers of

Blood Pressure ControlMarkers of Blood Pressure

Control ILI DSE P-value

Systolic BP (mmHg) BL

Systolic BP (mmHg) Y1

Y1 ndash Baseline

1282

1214

-68

1294

1266

-28

026

lt0001

lt0001

Diastolic BP (mmHg) BL

Diastolic BP (mmHg) Y1

Y1 ndash Baseline

699

670

-30

704

686

-18

011

lt0001

lt0001

Antihypertensive medications BL

Antihypertensive medications Y1

Y1 ndash Baseline

753

752

-01

737

759

22

023

054

002

1-Year Changes in Markers of Lipid

Control

Markers of Lipid Control ILI DSE P-value

LDL-cholesterol (mgdl) BL

LDL-cholesterol (mgdl) Y1

Y1 ndash Baseline

1122

1070

-52

1124

1067

-57

078

074

049

HDL-cholesterol (mgdl) BL

HDL-cholesterol (mgdl) Y1

Y1 ndash Baseline

435

469

34

436

449

14

080

lt0001

lt0001

Triglycerides (mgdl) BL

Triglycerides (mgdl) Y1

Y1 ndash Baseline

1828

1525

-303

1800

1654

-146

038

lt0001

lt0001

Lipid lowering medications BL

Lipid lowering medications Y1

Y1 ndash Baseline

494

530

37

484

578

94

052

lt0001

lt0001

1-Year Changes in Percent of Participants

Meeting ADA Goals

ADA Goal ILI DSE P-value

Hemoglobin A1c lt 7 BL

Hemoglobin A1c lt 7 Y1

Y1 ndash Baseline

463

727

264

454

508

54

050

lt0001

lt0001

Blood pressure lt 13080 mmHg BL

Blood pressure lt 13080 mmHg Y1

Y1 ndash Baseline

535

686

151

499

570

70

001

lt0001

lt0001

LDL-cholesterol lt 100 mgdl BL

LDL-cholesterol lt 100 mgdl Y1

Y1 ndash Baseline

371

438

67

369

449

80

087

045

034

All three goals BL

All three goals Y1

Y1 ndash Baseline

108

236

128

95

160

65

013

lt0001

lt0001

Mean Changes in Weight Fitness amp BP

Averaged Over Four Years

DSE

Mean

ILI

Mean

P-value

Weight Loss

( initial wt)

-088 -615 lt 00001

Fitness

( METS)

196 1274 lt00001

HbA1c -009 -036 lt 00001

SBP (mm Hg) -297 -533 lt 00001

DBP (mm Hg) -248 -292 0012

Look AHEAD Research Group Arch Int Med 2010

Mean Changes in Lipid Profile

Averaged Over Four Years

DSE

Mean

ILI

Mean

P-value

HDL (mgdl) 197 367 lt00001

TG (mgdl) -1975 -2556 00006

LDL (mgdl) -1284 -1127 0009

LDL (mgdl)

(Adjusting for

medication use)

-922 -875 042

Look AHEAD Research Group Arch Int Med 2010

Percent () Completing Outcome

Measures at Years 1-4

Intervention Group

(ILI)

Year 1 971

Year 2 949

Year 3 940

Year 4 941

Comparison Group

(DSE)

Year 1 957

Year 2 935

Year 3 938

Year 4 931

Look AHEAD Summary

ILI had significantly greater improvements than DSE in all CVD risk factors averaged across 4 years (except LDL-C)

There may be long-term beneficial effects from this 4-year period in which ILI subjects have been exposed to lower CVD risk factors

Longer follow-ups will determine whether these lowered CVD risk factors can be maintained amp whether lifestyle intervention has positive effects on CVD morbidity amp mortality

Mary J

Female

White

56 years old at start of Look AHEAD

study

Past Medical History Type 2 diabetes

overweight diverticulosis arthritis

sleep apnea back pain

Mary J

bullLong term strugglesbull Helping youngest daughter with

personal issues and children

bull Rotator cuff problems

bull Degenerative disks in back

bull Rheumatoid arthritis

bull Diabetes

bull Physically demanding job

bull Financial struggles

Pounds

Years

82007 grandkids enter pre-school

Catherine L

Female

White

47 years old at start of Look AHEAD

study

Past Medical History Type 2 diabetes

overweight high blood pressure

hypothyroidism back pain

Catherine L

Long term struggles

bull Motherrsquos declining health and death

bull Multiple serious injuries

bull Sudden death of sister

bull Death of step-father

bull Declining economy

bull Children living at home

Pounds

Years

Realistic Management Goals

5-10 weight loss

Health energy and fitness

Well-being and self-esteem

Mood and appearance

Functional and recreational

activity

Key Elements

Focus on health and energy

Food and physical activity diaries

Gradual increase in physical activity

Gradual reduction in dietary fat

No feelings of food deprivation

Social support groups

Recommended Strategies for Building

Sustainable Healthy Communities

Overview from USA

Promote the availability of affordable healthy

food and beverages

Support healthy food and beverage choices

Encourage breastfeeding

Encourage physical activity or limit sedentary

activity among children amp youth

Create safe communities that support physical

activity

Encourage communities to organize for change

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Increase the availability of healthier food and

beverage choices in public service venues (eg

schools city amp county buildings etc)

--Insufficient evidence in school-based programs

--Associations suggest availability amp increased

consumption

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve availability of affordable healthier

food amp beverage choices in public service

venues

--Reducing the cost of healthier foods

increases their purchase

--Providing coupons redeemable for

healthier foods increases their purchase

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve geographic availability of

supermarkets in underserved areas

-- Greater access to nearby supermarkets is

associated with healthier eating behaviors

-- Increasing the number of supermarkets in

underserved neighborhoods increased

real estate values increased economic

activity amp employment amp resulted in lower

food prices

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Provide incentives to food retailers to locate in

andor offer healthier food choices in

underserved areas

-- Presence of retail venues that provide healthier

foods is associated with better nutrition

-- Greater availability of supermarkets was

associated with lower adolescent BMI scores

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Improve availability of mechanisms for

purchasing foods from farms

--Evidence supporting a direct link between

purchasing food from farms amp improved diet is

limited

--Two studies of initiatives to encourage

participation in farmersrsquo market showed

increased intention to eat more fruits amp

vegetables but no direct evidence

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Provide incentives for the production

distribution and procurement of foods from local

farms

--No evidence has been published to link local

food production amp health outcomes

--There is a current study exploring the potential

nutritional amp health benefits of eating locally

grown foods

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Restrict availability of less healthy foods amp

beverages in public service venues

--No peer-reviewed studies examined the impact

designed to restrict availability of less healthy

foods in public service venues

--21 states have policies that restrict the sale of

competitive foods in schools beyond USDA

regulations however no studies have evaluated

the impact of the policies

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Institute smaller portion size options in public

service venues

--Evidence is lacking to demonstrate effectiveness

of population-based interventions aimed at

reducing portion sizes in public service venues

--Evidence from clinical studies in laboratories

demonstrates decreasing portion sizes

decreases energy intake

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Limit advertisements of less healthy foods amp

beverages

--Little evidence is available regarding the impact

of restricting advertising on purchasing amp

consumption of less healthy foods

--Cross-sectional time-series studies of tobacco-

control efforts suggest an association between

advertising bans amp decreased tobacco

consumption

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Discourage consumption of sugar-sweetened

beverages

--One longitudinal study of a school-based

intervention among Native-American high school

students showed a substantial reduction in

sugar-sweetened beverages over a 3-year

period

--A RCT of a home-based intervention that

eliminated sugar-sweetened beverages showed

reduction in BMI scores

Recommended Community Strategies Strategies to encourage breastfeeding

Increase support for breastfeeding

--Evidence directly linking environmental

interventions that support breastfeeding with

obesity-related outcomes is lacking

--Epidemiologic studies indicate that breastfeeding

helps prevent pediatric obesity

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Require physical education in schools

--14 studies have demonstrated that school-based

PE was effective in increasing levels of physical

activity and improving physical fitness

--Minimum of 150 minwk in elementary schools

225 minwk in middle schools and high schools

throughout the school year as recommended by

NASPE

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Increase opportunities for extracurricular

physical activity

--Participation in after-school programs increased

studentsrsquo level of physical activity amp improved

obesity-related outcomes (improved CV fitness

reduced body fat)

--2 pilot studies providing extracurricular physical

activity showed increased levels of PA amp

decreased sedentary behavior

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Reduce screen time in public service venues

--A school-based RCT indicated that children who

reduced their television videotape amp video

game use had significant decrease in BMI tricep

skin fold thickness amp waist circumference

compared to controls

--Spending less time watching television is

associated with increased physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Improve access to outdoor recreational

facilities

--Review of 108 studies indicated that access to facilities

and programs for recreation near their homes amp time

spent outdoors correlated positively with increased

physical activity among childrenamp adults

--Perceptions that footpaths are safe for walking was

significantly associated with adults being classified as

physically active at a level sufficient for health benefits

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting

bicycling

--Longitudinal intervention studies have

demonstrated that improving bicycling

infrastructure is associated with increased

frequency of bicycling

--Cross-sectional studies indicated a significant

association between bicycling infrastructure amp

frequency of biking

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting walking

--Reviews of cross-sectional studies of

environmental correlates of physical activity amp

walking generally find a positive association

between infrastructure supportive of walking amp

physical activity

--Identifying amp creating safe routes to school

together with educational components

increased the number of students walking to

school

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Locating schools within easy walking

distance of residential areas

--Community-scale urban design amp land use policies amp

practices including locating schools stores workplaces

amp recreation areas close to residential areas are

effective in facilitating an increase in levels of physical

activity

--Majority of efforts to encourage walking to school involve

improving the routes rather than improving the location

of schools

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Improve access to public transportation

--Insufficient evidence exists to determine

effectiveness of transportation policies in

increasing the level of physical activity or

improving fitness

--1 study indicated that 29 of individuals who

walk to and from public transit achieve at least

30 minutes of daily physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Zone for mixed-use development

--Allows residential commercial institutional amp

other public land uses to be located in close

proximity to one another

--Studies using correlation analyses amp regression

models indicated that mixed land use was

associated with increased walking amp cycling

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance personal safety in areas where

persons are or could be physically active

--Cross-sectional studies have demonstrated a

negative relationship between crime rates andor

perceived safety amp physical activity in

neighborhoods

--Few intervention studies have evaluated the

impact of policies amp practices to improve

personal safety on physical activity

Geospatial Mapping Linking Urban

Environments to Health Risk

Measure association between environmental variables amp health risk factors

Assess relationships between variables at different levels of analysis

Used in conjunction with linear analyses

Our Community Environmental Model

of Obesity

Community Factors

Poverty

Crime

Grocery Quality

Restaurants

Parks

Sidewalks

Fast Food Outlets

Recreational

Facilities

Individual Factors

Dietary Intake

Physical Activity

Genetics

Family History

StressCoping

Eating Disorders

Psychological

Problems

Weight

Status

Chosen Neighborhoods

Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped

We then matched census-block groups within the income groups by population density and percentage of minority representation

One matched block group per income level was randomly selected

Prevalence of Obesity in

Block-Groups

0

5

10

15

20

25

30

35

40

45

50

Ag

e-a

dju

sted

Ob

esit

y P

rev

ale

nce

(

)

High-Income Low-Income

Age-standardized to the 1990 US Census

Density of Environmental Factors in the

Community Contributes to a ldquoToxicrdquo

Obesity Environment

0

2

4

6

8

10

12

14

16

18

Fast-food Convenience Store Bars

Den

sity

10

00

perso

ns

High-Income Low-Income

COMMUNITYrsquoS PERCEPTION OF SAFETY

0

5

10

15

20

25

30

35

40

Daytime Nighttime

Perc

en

t (

) F

eeli

ng

So

mew

hat

Safe

or

Un

safe

Low-Income High-Income

Percent Substandard (or worse) Housing

or Ground Conditions

of Residential Properties

0

10

20

30

Structural Grounds

Perc

en

t (

)

Low-Income High-Income

CONCLUSIONS

These data suggest that the higher

frequency of outlets providing

calorically-dense foods and alcohol may

contribute to greater obesity prevalence

in residents of low-income communities

More research is needed to thoroughly

document environmental determinants

of health and obesity

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

From 1994-1998 HUD randomly assigned

4498 women with children living in public

housing in high-poverty urban census

tracts to one of three groups (1) housing

vouchers redeemable only if they moved

to a low-poverty census tract (2)

unrestricted vouchers or (3) control group

(no vouchers)

Ludwig et al NEJM 201136516

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

10-12 year follow-up showed modest but

potentially important reductions in the

prevalence of extreme obesity amp diabetes in the

group moving from a neighborhood with high

poverty on one of low poverty compared to the

control group

No differences between the group receiving

traditional vouchers amp the control group

ldquoNeighborhoods matterrdquo

Ludwig et al NEJM 201136516

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance traffic safety in areas where

persons are or could be physically active

--Community-scale urban design amp land use policies to

promote physical activity including design components

to improve street lighting infrastructure projects to

increase safety of pedestrian street crossing and use of

traffic calming approaches such as speed humps amp

traffic circles are effective in increasing physical activity

--Both community-scale amp street-scale policies amp practices

are effective in increasing physical activity

Recommended Community Strategies Encourage Communities to Organize for Change

Participate in community coalitions or

partnerships to address obesity

--Little evidence is available to determine the

impact of community coalitions on obesity

prevention

--The presence of anti-smoking community

coalitions has been associated with lower rates

of tobacco consumption

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

$103 million awarded to 61 states and

communities including state amp local government

agencies tribes amp territories amp state amp local non-

profit organizations

To build capacity to implement changes for

community prevention efforts to ensure long-

term success

To implement evidence-based and practice-

based programs to improve health amp wellness

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Priority areas are

Tobacco-free living

Active living and healthy eating

Evidence-based quality clinical and other

preventive health services for prevention

and control of high blood pressure and

high cholesterol

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Applicants proposed specific activities in

line with their chosen priority areas in their

applications

Grantee activities will not be finalized until

plans are negotiated with CDC by early

2012

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Capacity-Building Award

The Confederated Tribes of The Chehalis

Reservation is receiving a $498663 planning

award to build capacity to support healthy

lifestyles among their tribal population of 1500

in Washington State

Work will target tobacco-free living active living

and healthy eating and quality clinical and other

healthy serviceswwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Implementation Award

Austin TX Dept of Health and Human Services

is receiving $1026158 to serve Travis County

(Austin) to expand efforts in tobacco-free living

active living and healthy eating quality clinical

and other preventive services social and

emotional wellness and healthy and safe

physical environmentswwwcdcgov1052011

Building sustainable healthy

communities Bottom line

Obesity is an environmental problem

Despite progress in genetic research public health advances only will occur when we take the environment seriously

Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment

Until we do this we will not make substantial progress in addressing the epidemic of obesity

Poston amp Foreyt Atherosclerosis 1999

Whatrsquos the best approach

Integrate all sectors of society into community

change interventions

Incorporate

Science amp Technology

Education

FamilyCommunity

Healthcare

Arts amp Entertainment

Law amp Politics

Commerce amp Trade

Sectors of Society

Arts amp Entertainm

ent

Commerce amp Trade

Education

FamilyCommunity

Healthcare

Law amp Politics

Science amp Technology

Project FIT rationale design and baseline characteristics of a school- and community-

based intervention to address physical activity and healthy eating among low-income

elementary school children

Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D

Oh HJ Orth J Randall S Mayfield K Holmes D

Source

Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu

Abstract

BACKGROUND

This paper describes Project FIT a collaboration between the public school system local

health systems physicians neighborhood associations businesses faith-based leaders

community agencies and university researchers to develop a multi-faceted approach to

promote physical activity and healthy eating toward the general goal of preventing and

reducing childhood obesity among children in Grand Rapids MI USA

METHODSDESIGN

There are four overall components to Project FIT school community social marketing and

school staff wellness - all that focus on 1) increasing access to safe and affordable physical

activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)

improving the affordability and availability of nutritious food in the neighborhoods surrounding

the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding

nutrition and physical activity among school staff parents and students 4) impacting the

culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging

dialogue among all community partners to leverage existing programs and introduce new

ones

Efficacy-based comparative dietary guidelines

Carb Fat Pro

Mediterranean Diet 45-55 25-35 20

IOM Dietary Ref Intakes 45-65 25-35 15

NCEP-ATPIII 50-60 25-35 15

Am Dietetic Assoc 45-65 20-35 15

PARADOX OF INCREASING OBESITY

PREVALENCE

bull Focus on healthy eating and physical

activity

bull Awareness of dangers of obesity buthellip

bull Obesity prevalence continues to rise

bull Work amp commuting demands

bull Little time to exercise

bull Little time to prepare food

bull Availability of high-fatcalorie foods

Rationale for community-based interventions

bull Increases in obesity prevalence due to genes

bull Increased calories (eg 200 Kcalday

over 10 years)

bull Increased portion sizes (eg 22 oz

steaks and 44 oz sodas)

bull Western diets in developing nations

increase risk of obesity

READINESS TO CHANGE

ldquoHabit is habit and not to be

flung out of the window but

coaxed downstairs a step at a

timerdquo

Mark Twain

Long-Term Weight Maintenance

National Weight Control Registry (N=10000)

Survey of 3000 members who have been in the

Registry for at least 10 years

Starting weight = 224 lbs Average weight loss=69

lbs

At 5 years participants had maintained an average

weight loss=52 lbs

At 10 years participants had maintained an average

weight loss=51 lbs

Thomas Bond Phelan et al TOS 2011

Long-Term Weight Maintenance

Weight Maintainers report that they usually

Track their food intake

Count calories or fat grams

Follow a low-calorie low fat diet (1800 caloriesday

less than 30 of calories from fat

Eat breakfast regularly

Limit the amount they eat out (about 3 timesweek

eat fast food less than onceweek)

Thomas Bond Phelan et al TOS 2011

Long-Term Weight Maintenance

Weight Maintainers report that they usually

Eat similar food regularly

Donrsquot splurge much on holidays amp special occasions

Walk about one hourday

Watch less than 10 hours of TV a week

Weigh themselves at least once a week

Thomas Bond Phelan et al TOS 2011

LONG-TERM WEIGHT MAINTENANCE

Continued consumption of a low-

calorie diet with moderate fat intake

Limited fast food

High levels of physical activity

Phalen et al Obesity 2006 14 710-716

LONG-TERM WEIGHT MAINTENANCE

Daily weighing improved

maintenance of weight loss

particularly when delivered

face to face

Wing et al NEJM 2006 3551563-1571

Most Promising Strategies For

Preventing Weight Regain

Providing multi-component

programs with ongoing

professional contacts

Physical activityexercise

Portion controlmeal replacements

Extending treatment through

weekly or bi-weekly sessions

Pharmacotherapy

Perri Foreyt amp Anton Preventing Weight Regain After Weight Loss 2008

Most Promising Strategies For

Preventing Weight Regain

Extended treatments have shown

promise in promoting adherence to

the behaviors required for the long-

term maintenance of weight loss

Continuous care approach focused

on reasonable long-term objectives

appears appropriate for most

patients

Perri Foreyt amp Anton Preventing Weight Regain After Weight

Loss 2008

An Example of a successful long-term

intervention

The Look AHEAD Study

Does Weight Loss Reduce

Cardiovascular Disease and Death in

Overweight Individuals with Diabetes

bull Action for HEAlth in Diabetes

bull Objective to examine in overweight

persons with Type 2 Diabetes the long-

term effects of an intensive lifestyle

intervention program compared to

diabetes education and support

bull 16 Centers

bull 5145 overweight volunteers with

diabetes

Look AHEAD

Look AHEAD

Primary End Point Composite

bull Cardiovascular death (including fatal

myocardial infarction and stroke)

bull Non-fatal myocardial infarction

bull Non-fatal stroke

Winston-Salem

Baltimore

Philadelphia

New York

Providence

Boston

Clinical Site Coordinating Center

Clinical Sites

Seattle

Los Angeles

San AntonioHouston

Baton Rouge

Minneapolis

Memphis

Birmingham

Pittsburgh

Denver

Phoenix

Look AHEADParticipants

101100Baseline weight (kg)

589586Age (years)

9496Attended 1 year exam

360359Baseline BMI

1514Insulin Users

3737Minority

6059Women

(N=2574)(N=2630)

DSELifestyle

p lt 0004

Look AHEAD

Study Interventions

bull Diabetes support and education - DSE (control group)

bull Lifestyle intervention ndash ILI (treatment group)

Look AHEAD

Lifestyle Intervention

Goals

bull 7 weight loss for the group (10

for individual)

bull 175 minutes of moderate intensity

activity

Look AHEAD

Lifestyle Intervention

bull Diet

ndash ADA NCEP (lt 30 fat lt 10 sat fat

gt15 protein)

ndash 1200-1500 (if weight lt250lbs)

ndash 1500-1800 (if weight gt250lbs)

ndash During first 4 weeks to 4 months portion

control (liquid meal replacements or

structured meal plan)

Look AHEAD

Lifestyle Intervention

bull Physical Activity

ndash unsupervised

ndash 175 minutes moderate intensityweek

ndash 5 daysweek

ndash walking

Weight Loss at 1-Year

-9

ILI 0

-1

-2

-3

-4

-5

-6

-7

-8

DSE

p lt 00001

W

eig

ht

Chan

ge

86

07

The Look AHEAD Research Group Diabetes Care 2007

Reduction in Initial Weight by Gender

N=872

N=1229N=1197

N=830

-12

-10

-8

-6

-4

-2

0

0 2 4 6 8 10 12

Months

R

ed

uctio

n in

In

itia

l W

eig

ht

Men

Women

Plt0001

The Look AHEAD Research Group Diabetes Care 2007

Fitness Change () at 1-Year

0

5

10

15

20

25

Mean

Fitness C

hange

Unadjusted

Plt0001Adjusted for 1 Year

Weight Change Plt0001

58

209

108

159

DSE ILI ILIDSE

The Look AHEAD Research Group Diabetes Care 2007

1-Year Changes in Markers of

Diabetes Control

Markers of Diabetes

Control ILI DSE P-value

Hemoglobin A1c () BL

Hemoglobin A1c () Y1

Y1 ndash Baseline

725

661

-064

729

715

-014

026

lt0001

lt0001

Fasting glucose (mgdl) BL

Fasting glucose (mgdl) Y1

Y1 ndash Baseline

1519

1304

-215

1536

1464

-72

021

lt0001

lt0001

Diabetes medications BL

Diabetes medications Y1

Y1 ndash Baseline

865

786

-78

865

887

22

093

lt0001

lt0001

1-Year Changes in Markers of

Blood Pressure ControlMarkers of Blood Pressure

Control ILI DSE P-value

Systolic BP (mmHg) BL

Systolic BP (mmHg) Y1

Y1 ndash Baseline

1282

1214

-68

1294

1266

-28

026

lt0001

lt0001

Diastolic BP (mmHg) BL

Diastolic BP (mmHg) Y1

Y1 ndash Baseline

699

670

-30

704

686

-18

011

lt0001

lt0001

Antihypertensive medications BL

Antihypertensive medications Y1

Y1 ndash Baseline

753

752

-01

737

759

22

023

054

002

1-Year Changes in Markers of Lipid

Control

Markers of Lipid Control ILI DSE P-value

LDL-cholesterol (mgdl) BL

LDL-cholesterol (mgdl) Y1

Y1 ndash Baseline

1122

1070

-52

1124

1067

-57

078

074

049

HDL-cholesterol (mgdl) BL

HDL-cholesterol (mgdl) Y1

Y1 ndash Baseline

435

469

34

436

449

14

080

lt0001

lt0001

Triglycerides (mgdl) BL

Triglycerides (mgdl) Y1

Y1 ndash Baseline

1828

1525

-303

1800

1654

-146

038

lt0001

lt0001

Lipid lowering medications BL

Lipid lowering medications Y1

Y1 ndash Baseline

494

530

37

484

578

94

052

lt0001

lt0001

1-Year Changes in Percent of Participants

Meeting ADA Goals

ADA Goal ILI DSE P-value

Hemoglobin A1c lt 7 BL

Hemoglobin A1c lt 7 Y1

Y1 ndash Baseline

463

727

264

454

508

54

050

lt0001

lt0001

Blood pressure lt 13080 mmHg BL

Blood pressure lt 13080 mmHg Y1

Y1 ndash Baseline

535

686

151

499

570

70

001

lt0001

lt0001

LDL-cholesterol lt 100 mgdl BL

LDL-cholesterol lt 100 mgdl Y1

Y1 ndash Baseline

371

438

67

369

449

80

087

045

034

All three goals BL

All three goals Y1

Y1 ndash Baseline

108

236

128

95

160

65

013

lt0001

lt0001

Mean Changes in Weight Fitness amp BP

Averaged Over Four Years

DSE

Mean

ILI

Mean

P-value

Weight Loss

( initial wt)

-088 -615 lt 00001

Fitness

( METS)

196 1274 lt00001

HbA1c -009 -036 lt 00001

SBP (mm Hg) -297 -533 lt 00001

DBP (mm Hg) -248 -292 0012

Look AHEAD Research Group Arch Int Med 2010

Mean Changes in Lipid Profile

Averaged Over Four Years

DSE

Mean

ILI

Mean

P-value

HDL (mgdl) 197 367 lt00001

TG (mgdl) -1975 -2556 00006

LDL (mgdl) -1284 -1127 0009

LDL (mgdl)

(Adjusting for

medication use)

-922 -875 042

Look AHEAD Research Group Arch Int Med 2010

Percent () Completing Outcome

Measures at Years 1-4

Intervention Group

(ILI)

Year 1 971

Year 2 949

Year 3 940

Year 4 941

Comparison Group

(DSE)

Year 1 957

Year 2 935

Year 3 938

Year 4 931

Look AHEAD Summary

ILI had significantly greater improvements than DSE in all CVD risk factors averaged across 4 years (except LDL-C)

There may be long-term beneficial effects from this 4-year period in which ILI subjects have been exposed to lower CVD risk factors

Longer follow-ups will determine whether these lowered CVD risk factors can be maintained amp whether lifestyle intervention has positive effects on CVD morbidity amp mortality

Mary J

Female

White

56 years old at start of Look AHEAD

study

Past Medical History Type 2 diabetes

overweight diverticulosis arthritis

sleep apnea back pain

Mary J

bullLong term strugglesbull Helping youngest daughter with

personal issues and children

bull Rotator cuff problems

bull Degenerative disks in back

bull Rheumatoid arthritis

bull Diabetes

bull Physically demanding job

bull Financial struggles

Pounds

Years

82007 grandkids enter pre-school

Catherine L

Female

White

47 years old at start of Look AHEAD

study

Past Medical History Type 2 diabetes

overweight high blood pressure

hypothyroidism back pain

Catherine L

Long term struggles

bull Motherrsquos declining health and death

bull Multiple serious injuries

bull Sudden death of sister

bull Death of step-father

bull Declining economy

bull Children living at home

Pounds

Years

Realistic Management Goals

5-10 weight loss

Health energy and fitness

Well-being and self-esteem

Mood and appearance

Functional and recreational

activity

Key Elements

Focus on health and energy

Food and physical activity diaries

Gradual increase in physical activity

Gradual reduction in dietary fat

No feelings of food deprivation

Social support groups

Recommended Strategies for Building

Sustainable Healthy Communities

Overview from USA

Promote the availability of affordable healthy

food and beverages

Support healthy food and beverage choices

Encourage breastfeeding

Encourage physical activity or limit sedentary

activity among children amp youth

Create safe communities that support physical

activity

Encourage communities to organize for change

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Increase the availability of healthier food and

beverage choices in public service venues (eg

schools city amp county buildings etc)

--Insufficient evidence in school-based programs

--Associations suggest availability amp increased

consumption

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve availability of affordable healthier

food amp beverage choices in public service

venues

--Reducing the cost of healthier foods

increases their purchase

--Providing coupons redeemable for

healthier foods increases their purchase

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve geographic availability of

supermarkets in underserved areas

-- Greater access to nearby supermarkets is

associated with healthier eating behaviors

-- Increasing the number of supermarkets in

underserved neighborhoods increased

real estate values increased economic

activity amp employment amp resulted in lower

food prices

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Provide incentives to food retailers to locate in

andor offer healthier food choices in

underserved areas

-- Presence of retail venues that provide healthier

foods is associated with better nutrition

-- Greater availability of supermarkets was

associated with lower adolescent BMI scores

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Improve availability of mechanisms for

purchasing foods from farms

--Evidence supporting a direct link between

purchasing food from farms amp improved diet is

limited

--Two studies of initiatives to encourage

participation in farmersrsquo market showed

increased intention to eat more fruits amp

vegetables but no direct evidence

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Provide incentives for the production

distribution and procurement of foods from local

farms

--No evidence has been published to link local

food production amp health outcomes

--There is a current study exploring the potential

nutritional amp health benefits of eating locally

grown foods

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Restrict availability of less healthy foods amp

beverages in public service venues

--No peer-reviewed studies examined the impact

designed to restrict availability of less healthy

foods in public service venues

--21 states have policies that restrict the sale of

competitive foods in schools beyond USDA

regulations however no studies have evaluated

the impact of the policies

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Institute smaller portion size options in public

service venues

--Evidence is lacking to demonstrate effectiveness

of population-based interventions aimed at

reducing portion sizes in public service venues

--Evidence from clinical studies in laboratories

demonstrates decreasing portion sizes

decreases energy intake

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Limit advertisements of less healthy foods amp

beverages

--Little evidence is available regarding the impact

of restricting advertising on purchasing amp

consumption of less healthy foods

--Cross-sectional time-series studies of tobacco-

control efforts suggest an association between

advertising bans amp decreased tobacco

consumption

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Discourage consumption of sugar-sweetened

beverages

--One longitudinal study of a school-based

intervention among Native-American high school

students showed a substantial reduction in

sugar-sweetened beverages over a 3-year

period

--A RCT of a home-based intervention that

eliminated sugar-sweetened beverages showed

reduction in BMI scores

Recommended Community Strategies Strategies to encourage breastfeeding

Increase support for breastfeeding

--Evidence directly linking environmental

interventions that support breastfeeding with

obesity-related outcomes is lacking

--Epidemiologic studies indicate that breastfeeding

helps prevent pediatric obesity

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Require physical education in schools

--14 studies have demonstrated that school-based

PE was effective in increasing levels of physical

activity and improving physical fitness

--Minimum of 150 minwk in elementary schools

225 minwk in middle schools and high schools

throughout the school year as recommended by

NASPE

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Increase opportunities for extracurricular

physical activity

--Participation in after-school programs increased

studentsrsquo level of physical activity amp improved

obesity-related outcomes (improved CV fitness

reduced body fat)

--2 pilot studies providing extracurricular physical

activity showed increased levels of PA amp

decreased sedentary behavior

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Reduce screen time in public service venues

--A school-based RCT indicated that children who

reduced their television videotape amp video

game use had significant decrease in BMI tricep

skin fold thickness amp waist circumference

compared to controls

--Spending less time watching television is

associated with increased physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Improve access to outdoor recreational

facilities

--Review of 108 studies indicated that access to facilities

and programs for recreation near their homes amp time

spent outdoors correlated positively with increased

physical activity among childrenamp adults

--Perceptions that footpaths are safe for walking was

significantly associated with adults being classified as

physically active at a level sufficient for health benefits

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting

bicycling

--Longitudinal intervention studies have

demonstrated that improving bicycling

infrastructure is associated with increased

frequency of bicycling

--Cross-sectional studies indicated a significant

association between bicycling infrastructure amp

frequency of biking

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting walking

--Reviews of cross-sectional studies of

environmental correlates of physical activity amp

walking generally find a positive association

between infrastructure supportive of walking amp

physical activity

--Identifying amp creating safe routes to school

together with educational components

increased the number of students walking to

school

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Locating schools within easy walking

distance of residential areas

--Community-scale urban design amp land use policies amp

practices including locating schools stores workplaces

amp recreation areas close to residential areas are

effective in facilitating an increase in levels of physical

activity

--Majority of efforts to encourage walking to school involve

improving the routes rather than improving the location

of schools

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Improve access to public transportation

--Insufficient evidence exists to determine

effectiveness of transportation policies in

increasing the level of physical activity or

improving fitness

--1 study indicated that 29 of individuals who

walk to and from public transit achieve at least

30 minutes of daily physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Zone for mixed-use development

--Allows residential commercial institutional amp

other public land uses to be located in close

proximity to one another

--Studies using correlation analyses amp regression

models indicated that mixed land use was

associated with increased walking amp cycling

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance personal safety in areas where

persons are or could be physically active

--Cross-sectional studies have demonstrated a

negative relationship between crime rates andor

perceived safety amp physical activity in

neighborhoods

--Few intervention studies have evaluated the

impact of policies amp practices to improve

personal safety on physical activity

Geospatial Mapping Linking Urban

Environments to Health Risk

Measure association between environmental variables amp health risk factors

Assess relationships between variables at different levels of analysis

Used in conjunction with linear analyses

Our Community Environmental Model

of Obesity

Community Factors

Poverty

Crime

Grocery Quality

Restaurants

Parks

Sidewalks

Fast Food Outlets

Recreational

Facilities

Individual Factors

Dietary Intake

Physical Activity

Genetics

Family History

StressCoping

Eating Disorders

Psychological

Problems

Weight

Status

Chosen Neighborhoods

Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped

We then matched census-block groups within the income groups by population density and percentage of minority representation

One matched block group per income level was randomly selected

Prevalence of Obesity in

Block-Groups

0

5

10

15

20

25

30

35

40

45

50

Ag

e-a

dju

sted

Ob

esit

y P

rev

ale

nce

(

)

High-Income Low-Income

Age-standardized to the 1990 US Census

Density of Environmental Factors in the

Community Contributes to a ldquoToxicrdquo

Obesity Environment

0

2

4

6

8

10

12

14

16

18

Fast-food Convenience Store Bars

Den

sity

10

00

perso

ns

High-Income Low-Income

COMMUNITYrsquoS PERCEPTION OF SAFETY

0

5

10

15

20

25

30

35

40

Daytime Nighttime

Perc

en

t (

) F

eeli

ng

So

mew

hat

Safe

or

Un

safe

Low-Income High-Income

Percent Substandard (or worse) Housing

or Ground Conditions

of Residential Properties

0

10

20

30

Structural Grounds

Perc

en

t (

)

Low-Income High-Income

CONCLUSIONS

These data suggest that the higher

frequency of outlets providing

calorically-dense foods and alcohol may

contribute to greater obesity prevalence

in residents of low-income communities

More research is needed to thoroughly

document environmental determinants

of health and obesity

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

From 1994-1998 HUD randomly assigned

4498 women with children living in public

housing in high-poverty urban census

tracts to one of three groups (1) housing

vouchers redeemable only if they moved

to a low-poverty census tract (2)

unrestricted vouchers or (3) control group

(no vouchers)

Ludwig et al NEJM 201136516

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

10-12 year follow-up showed modest but

potentially important reductions in the

prevalence of extreme obesity amp diabetes in the

group moving from a neighborhood with high

poverty on one of low poverty compared to the

control group

No differences between the group receiving

traditional vouchers amp the control group

ldquoNeighborhoods matterrdquo

Ludwig et al NEJM 201136516

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance traffic safety in areas where

persons are or could be physically active

--Community-scale urban design amp land use policies to

promote physical activity including design components

to improve street lighting infrastructure projects to

increase safety of pedestrian street crossing and use of

traffic calming approaches such as speed humps amp

traffic circles are effective in increasing physical activity

--Both community-scale amp street-scale policies amp practices

are effective in increasing physical activity

Recommended Community Strategies Encourage Communities to Organize for Change

Participate in community coalitions or

partnerships to address obesity

--Little evidence is available to determine the

impact of community coalitions on obesity

prevention

--The presence of anti-smoking community

coalitions has been associated with lower rates

of tobacco consumption

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

$103 million awarded to 61 states and

communities including state amp local government

agencies tribes amp territories amp state amp local non-

profit organizations

To build capacity to implement changes for

community prevention efforts to ensure long-

term success

To implement evidence-based and practice-

based programs to improve health amp wellness

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Priority areas are

Tobacco-free living

Active living and healthy eating

Evidence-based quality clinical and other

preventive health services for prevention

and control of high blood pressure and

high cholesterol

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Applicants proposed specific activities in

line with their chosen priority areas in their

applications

Grantee activities will not be finalized until

plans are negotiated with CDC by early

2012

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Capacity-Building Award

The Confederated Tribes of The Chehalis

Reservation is receiving a $498663 planning

award to build capacity to support healthy

lifestyles among their tribal population of 1500

in Washington State

Work will target tobacco-free living active living

and healthy eating and quality clinical and other

healthy serviceswwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Implementation Award

Austin TX Dept of Health and Human Services

is receiving $1026158 to serve Travis County

(Austin) to expand efforts in tobacco-free living

active living and healthy eating quality clinical

and other preventive services social and

emotional wellness and healthy and safe

physical environmentswwwcdcgov1052011

Building sustainable healthy

communities Bottom line

Obesity is an environmental problem

Despite progress in genetic research public health advances only will occur when we take the environment seriously

Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment

Until we do this we will not make substantial progress in addressing the epidemic of obesity

Poston amp Foreyt Atherosclerosis 1999

Whatrsquos the best approach

Integrate all sectors of society into community

change interventions

Incorporate

Science amp Technology

Education

FamilyCommunity

Healthcare

Arts amp Entertainment

Law amp Politics

Commerce amp Trade

Sectors of Society

Arts amp Entertainm

ent

Commerce amp Trade

Education

FamilyCommunity

Healthcare

Law amp Politics

Science amp Technology

Project FIT rationale design and baseline characteristics of a school- and community-

based intervention to address physical activity and healthy eating among low-income

elementary school children

Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D

Oh HJ Orth J Randall S Mayfield K Holmes D

Source

Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu

Abstract

BACKGROUND

This paper describes Project FIT a collaboration between the public school system local

health systems physicians neighborhood associations businesses faith-based leaders

community agencies and university researchers to develop a multi-faceted approach to

promote physical activity and healthy eating toward the general goal of preventing and

reducing childhood obesity among children in Grand Rapids MI USA

METHODSDESIGN

There are four overall components to Project FIT school community social marketing and

school staff wellness - all that focus on 1) increasing access to safe and affordable physical

activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)

improving the affordability and availability of nutritious food in the neighborhoods surrounding

the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding

nutrition and physical activity among school staff parents and students 4) impacting the

culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging

dialogue among all community partners to leverage existing programs and introduce new

ones

PARADOX OF INCREASING OBESITY

PREVALENCE

bull Focus on healthy eating and physical

activity

bull Awareness of dangers of obesity buthellip

bull Obesity prevalence continues to rise

bull Work amp commuting demands

bull Little time to exercise

bull Little time to prepare food

bull Availability of high-fatcalorie foods

Rationale for community-based interventions

bull Increases in obesity prevalence due to genes

bull Increased calories (eg 200 Kcalday

over 10 years)

bull Increased portion sizes (eg 22 oz

steaks and 44 oz sodas)

bull Western diets in developing nations

increase risk of obesity

READINESS TO CHANGE

ldquoHabit is habit and not to be

flung out of the window but

coaxed downstairs a step at a

timerdquo

Mark Twain

Long-Term Weight Maintenance

National Weight Control Registry (N=10000)

Survey of 3000 members who have been in the

Registry for at least 10 years

Starting weight = 224 lbs Average weight loss=69

lbs

At 5 years participants had maintained an average

weight loss=52 lbs

At 10 years participants had maintained an average

weight loss=51 lbs

Thomas Bond Phelan et al TOS 2011

Long-Term Weight Maintenance

Weight Maintainers report that they usually

Track their food intake

Count calories or fat grams

Follow a low-calorie low fat diet (1800 caloriesday

less than 30 of calories from fat

Eat breakfast regularly

Limit the amount they eat out (about 3 timesweek

eat fast food less than onceweek)

Thomas Bond Phelan et al TOS 2011

Long-Term Weight Maintenance

Weight Maintainers report that they usually

Eat similar food regularly

Donrsquot splurge much on holidays amp special occasions

Walk about one hourday

Watch less than 10 hours of TV a week

Weigh themselves at least once a week

Thomas Bond Phelan et al TOS 2011

LONG-TERM WEIGHT MAINTENANCE

Continued consumption of a low-

calorie diet with moderate fat intake

Limited fast food

High levels of physical activity

Phalen et al Obesity 2006 14 710-716

LONG-TERM WEIGHT MAINTENANCE

Daily weighing improved

maintenance of weight loss

particularly when delivered

face to face

Wing et al NEJM 2006 3551563-1571

Most Promising Strategies For

Preventing Weight Regain

Providing multi-component

programs with ongoing

professional contacts

Physical activityexercise

Portion controlmeal replacements

Extending treatment through

weekly or bi-weekly sessions

Pharmacotherapy

Perri Foreyt amp Anton Preventing Weight Regain After Weight Loss 2008

Most Promising Strategies For

Preventing Weight Regain

Extended treatments have shown

promise in promoting adherence to

the behaviors required for the long-

term maintenance of weight loss

Continuous care approach focused

on reasonable long-term objectives

appears appropriate for most

patients

Perri Foreyt amp Anton Preventing Weight Regain After Weight

Loss 2008

An Example of a successful long-term

intervention

The Look AHEAD Study

Does Weight Loss Reduce

Cardiovascular Disease and Death in

Overweight Individuals with Diabetes

bull Action for HEAlth in Diabetes

bull Objective to examine in overweight

persons with Type 2 Diabetes the long-

term effects of an intensive lifestyle

intervention program compared to

diabetes education and support

bull 16 Centers

bull 5145 overweight volunteers with

diabetes

Look AHEAD

Look AHEAD

Primary End Point Composite

bull Cardiovascular death (including fatal

myocardial infarction and stroke)

bull Non-fatal myocardial infarction

bull Non-fatal stroke

Winston-Salem

Baltimore

Philadelphia

New York

Providence

Boston

Clinical Site Coordinating Center

Clinical Sites

Seattle

Los Angeles

San AntonioHouston

Baton Rouge

Minneapolis

Memphis

Birmingham

Pittsburgh

Denver

Phoenix

Look AHEADParticipants

101100Baseline weight (kg)

589586Age (years)

9496Attended 1 year exam

360359Baseline BMI

1514Insulin Users

3737Minority

6059Women

(N=2574)(N=2630)

DSELifestyle

p lt 0004

Look AHEAD

Study Interventions

bull Diabetes support and education - DSE (control group)

bull Lifestyle intervention ndash ILI (treatment group)

Look AHEAD

Lifestyle Intervention

Goals

bull 7 weight loss for the group (10

for individual)

bull 175 minutes of moderate intensity

activity

Look AHEAD

Lifestyle Intervention

bull Diet

ndash ADA NCEP (lt 30 fat lt 10 sat fat

gt15 protein)

ndash 1200-1500 (if weight lt250lbs)

ndash 1500-1800 (if weight gt250lbs)

ndash During first 4 weeks to 4 months portion

control (liquid meal replacements or

structured meal plan)

Look AHEAD

Lifestyle Intervention

bull Physical Activity

ndash unsupervised

ndash 175 minutes moderate intensityweek

ndash 5 daysweek

ndash walking

Weight Loss at 1-Year

-9

ILI 0

-1

-2

-3

-4

-5

-6

-7

-8

DSE

p lt 00001

W

eig

ht

Chan

ge

86

07

The Look AHEAD Research Group Diabetes Care 2007

Reduction in Initial Weight by Gender

N=872

N=1229N=1197

N=830

-12

-10

-8

-6

-4

-2

0

0 2 4 6 8 10 12

Months

R

ed

uctio

n in

In

itia

l W

eig

ht

Men

Women

Plt0001

The Look AHEAD Research Group Diabetes Care 2007

Fitness Change () at 1-Year

0

5

10

15

20

25

Mean

Fitness C

hange

Unadjusted

Plt0001Adjusted for 1 Year

Weight Change Plt0001

58

209

108

159

DSE ILI ILIDSE

The Look AHEAD Research Group Diabetes Care 2007

1-Year Changes in Markers of

Diabetes Control

Markers of Diabetes

Control ILI DSE P-value

Hemoglobin A1c () BL

Hemoglobin A1c () Y1

Y1 ndash Baseline

725

661

-064

729

715

-014

026

lt0001

lt0001

Fasting glucose (mgdl) BL

Fasting glucose (mgdl) Y1

Y1 ndash Baseline

1519

1304

-215

1536

1464

-72

021

lt0001

lt0001

Diabetes medications BL

Diabetes medications Y1

Y1 ndash Baseline

865

786

-78

865

887

22

093

lt0001

lt0001

1-Year Changes in Markers of

Blood Pressure ControlMarkers of Blood Pressure

Control ILI DSE P-value

Systolic BP (mmHg) BL

Systolic BP (mmHg) Y1

Y1 ndash Baseline

1282

1214

-68

1294

1266

-28

026

lt0001

lt0001

Diastolic BP (mmHg) BL

Diastolic BP (mmHg) Y1

Y1 ndash Baseline

699

670

-30

704

686

-18

011

lt0001

lt0001

Antihypertensive medications BL

Antihypertensive medications Y1

Y1 ndash Baseline

753

752

-01

737

759

22

023

054

002

1-Year Changes in Markers of Lipid

Control

Markers of Lipid Control ILI DSE P-value

LDL-cholesterol (mgdl) BL

LDL-cholesterol (mgdl) Y1

Y1 ndash Baseline

1122

1070

-52

1124

1067

-57

078

074

049

HDL-cholesterol (mgdl) BL

HDL-cholesterol (mgdl) Y1

Y1 ndash Baseline

435

469

34

436

449

14

080

lt0001

lt0001

Triglycerides (mgdl) BL

Triglycerides (mgdl) Y1

Y1 ndash Baseline

1828

1525

-303

1800

1654

-146

038

lt0001

lt0001

Lipid lowering medications BL

Lipid lowering medications Y1

Y1 ndash Baseline

494

530

37

484

578

94

052

lt0001

lt0001

1-Year Changes in Percent of Participants

Meeting ADA Goals

ADA Goal ILI DSE P-value

Hemoglobin A1c lt 7 BL

Hemoglobin A1c lt 7 Y1

Y1 ndash Baseline

463

727

264

454

508

54

050

lt0001

lt0001

Blood pressure lt 13080 mmHg BL

Blood pressure lt 13080 mmHg Y1

Y1 ndash Baseline

535

686

151

499

570

70

001

lt0001

lt0001

LDL-cholesterol lt 100 mgdl BL

LDL-cholesterol lt 100 mgdl Y1

Y1 ndash Baseline

371

438

67

369

449

80

087

045

034

All three goals BL

All three goals Y1

Y1 ndash Baseline

108

236

128

95

160

65

013

lt0001

lt0001

Mean Changes in Weight Fitness amp BP

Averaged Over Four Years

DSE

Mean

ILI

Mean

P-value

Weight Loss

( initial wt)

-088 -615 lt 00001

Fitness

( METS)

196 1274 lt00001

HbA1c -009 -036 lt 00001

SBP (mm Hg) -297 -533 lt 00001

DBP (mm Hg) -248 -292 0012

Look AHEAD Research Group Arch Int Med 2010

Mean Changes in Lipid Profile

Averaged Over Four Years

DSE

Mean

ILI

Mean

P-value

HDL (mgdl) 197 367 lt00001

TG (mgdl) -1975 -2556 00006

LDL (mgdl) -1284 -1127 0009

LDL (mgdl)

(Adjusting for

medication use)

-922 -875 042

Look AHEAD Research Group Arch Int Med 2010

Percent () Completing Outcome

Measures at Years 1-4

Intervention Group

(ILI)

Year 1 971

Year 2 949

Year 3 940

Year 4 941

Comparison Group

(DSE)

Year 1 957

Year 2 935

Year 3 938

Year 4 931

Look AHEAD Summary

ILI had significantly greater improvements than DSE in all CVD risk factors averaged across 4 years (except LDL-C)

There may be long-term beneficial effects from this 4-year period in which ILI subjects have been exposed to lower CVD risk factors

Longer follow-ups will determine whether these lowered CVD risk factors can be maintained amp whether lifestyle intervention has positive effects on CVD morbidity amp mortality

Mary J

Female

White

56 years old at start of Look AHEAD

study

Past Medical History Type 2 diabetes

overweight diverticulosis arthritis

sleep apnea back pain

Mary J

bullLong term strugglesbull Helping youngest daughter with

personal issues and children

bull Rotator cuff problems

bull Degenerative disks in back

bull Rheumatoid arthritis

bull Diabetes

bull Physically demanding job

bull Financial struggles

Pounds

Years

82007 grandkids enter pre-school

Catherine L

Female

White

47 years old at start of Look AHEAD

study

Past Medical History Type 2 diabetes

overweight high blood pressure

hypothyroidism back pain

Catherine L

Long term struggles

bull Motherrsquos declining health and death

bull Multiple serious injuries

bull Sudden death of sister

bull Death of step-father

bull Declining economy

bull Children living at home

Pounds

Years

Realistic Management Goals

5-10 weight loss

Health energy and fitness

Well-being and self-esteem

Mood and appearance

Functional and recreational

activity

Key Elements

Focus on health and energy

Food and physical activity diaries

Gradual increase in physical activity

Gradual reduction in dietary fat

No feelings of food deprivation

Social support groups

Recommended Strategies for Building

Sustainable Healthy Communities

Overview from USA

Promote the availability of affordable healthy

food and beverages

Support healthy food and beverage choices

Encourage breastfeeding

Encourage physical activity or limit sedentary

activity among children amp youth

Create safe communities that support physical

activity

Encourage communities to organize for change

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Increase the availability of healthier food and

beverage choices in public service venues (eg

schools city amp county buildings etc)

--Insufficient evidence in school-based programs

--Associations suggest availability amp increased

consumption

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve availability of affordable healthier

food amp beverage choices in public service

venues

--Reducing the cost of healthier foods

increases their purchase

--Providing coupons redeemable for

healthier foods increases their purchase

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve geographic availability of

supermarkets in underserved areas

-- Greater access to nearby supermarkets is

associated with healthier eating behaviors

-- Increasing the number of supermarkets in

underserved neighborhoods increased

real estate values increased economic

activity amp employment amp resulted in lower

food prices

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Provide incentives to food retailers to locate in

andor offer healthier food choices in

underserved areas

-- Presence of retail venues that provide healthier

foods is associated with better nutrition

-- Greater availability of supermarkets was

associated with lower adolescent BMI scores

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Improve availability of mechanisms for

purchasing foods from farms

--Evidence supporting a direct link between

purchasing food from farms amp improved diet is

limited

--Two studies of initiatives to encourage

participation in farmersrsquo market showed

increased intention to eat more fruits amp

vegetables but no direct evidence

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Provide incentives for the production

distribution and procurement of foods from local

farms

--No evidence has been published to link local

food production amp health outcomes

--There is a current study exploring the potential

nutritional amp health benefits of eating locally

grown foods

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Restrict availability of less healthy foods amp

beverages in public service venues

--No peer-reviewed studies examined the impact

designed to restrict availability of less healthy

foods in public service venues

--21 states have policies that restrict the sale of

competitive foods in schools beyond USDA

regulations however no studies have evaluated

the impact of the policies

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Institute smaller portion size options in public

service venues

--Evidence is lacking to demonstrate effectiveness

of population-based interventions aimed at

reducing portion sizes in public service venues

--Evidence from clinical studies in laboratories

demonstrates decreasing portion sizes

decreases energy intake

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Limit advertisements of less healthy foods amp

beverages

--Little evidence is available regarding the impact

of restricting advertising on purchasing amp

consumption of less healthy foods

--Cross-sectional time-series studies of tobacco-

control efforts suggest an association between

advertising bans amp decreased tobacco

consumption

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Discourage consumption of sugar-sweetened

beverages

--One longitudinal study of a school-based

intervention among Native-American high school

students showed a substantial reduction in

sugar-sweetened beverages over a 3-year

period

--A RCT of a home-based intervention that

eliminated sugar-sweetened beverages showed

reduction in BMI scores

Recommended Community Strategies Strategies to encourage breastfeeding

Increase support for breastfeeding

--Evidence directly linking environmental

interventions that support breastfeeding with

obesity-related outcomes is lacking

--Epidemiologic studies indicate that breastfeeding

helps prevent pediatric obesity

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Require physical education in schools

--14 studies have demonstrated that school-based

PE was effective in increasing levels of physical

activity and improving physical fitness

--Minimum of 150 minwk in elementary schools

225 minwk in middle schools and high schools

throughout the school year as recommended by

NASPE

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Increase opportunities for extracurricular

physical activity

--Participation in after-school programs increased

studentsrsquo level of physical activity amp improved

obesity-related outcomes (improved CV fitness

reduced body fat)

--2 pilot studies providing extracurricular physical

activity showed increased levels of PA amp

decreased sedentary behavior

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Reduce screen time in public service venues

--A school-based RCT indicated that children who

reduced their television videotape amp video

game use had significant decrease in BMI tricep

skin fold thickness amp waist circumference

compared to controls

--Spending less time watching television is

associated with increased physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Improve access to outdoor recreational

facilities

--Review of 108 studies indicated that access to facilities

and programs for recreation near their homes amp time

spent outdoors correlated positively with increased

physical activity among childrenamp adults

--Perceptions that footpaths are safe for walking was

significantly associated with adults being classified as

physically active at a level sufficient for health benefits

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting

bicycling

--Longitudinal intervention studies have

demonstrated that improving bicycling

infrastructure is associated with increased

frequency of bicycling

--Cross-sectional studies indicated a significant

association between bicycling infrastructure amp

frequency of biking

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting walking

--Reviews of cross-sectional studies of

environmental correlates of physical activity amp

walking generally find a positive association

between infrastructure supportive of walking amp

physical activity

--Identifying amp creating safe routes to school

together with educational components

increased the number of students walking to

school

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Locating schools within easy walking

distance of residential areas

--Community-scale urban design amp land use policies amp

practices including locating schools stores workplaces

amp recreation areas close to residential areas are

effective in facilitating an increase in levels of physical

activity

--Majority of efforts to encourage walking to school involve

improving the routes rather than improving the location

of schools

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Improve access to public transportation

--Insufficient evidence exists to determine

effectiveness of transportation policies in

increasing the level of physical activity or

improving fitness

--1 study indicated that 29 of individuals who

walk to and from public transit achieve at least

30 minutes of daily physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Zone for mixed-use development

--Allows residential commercial institutional amp

other public land uses to be located in close

proximity to one another

--Studies using correlation analyses amp regression

models indicated that mixed land use was

associated with increased walking amp cycling

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance personal safety in areas where

persons are or could be physically active

--Cross-sectional studies have demonstrated a

negative relationship between crime rates andor

perceived safety amp physical activity in

neighborhoods

--Few intervention studies have evaluated the

impact of policies amp practices to improve

personal safety on physical activity

Geospatial Mapping Linking Urban

Environments to Health Risk

Measure association between environmental variables amp health risk factors

Assess relationships between variables at different levels of analysis

Used in conjunction with linear analyses

Our Community Environmental Model

of Obesity

Community Factors

Poverty

Crime

Grocery Quality

Restaurants

Parks

Sidewalks

Fast Food Outlets

Recreational

Facilities

Individual Factors

Dietary Intake

Physical Activity

Genetics

Family History

StressCoping

Eating Disorders

Psychological

Problems

Weight

Status

Chosen Neighborhoods

Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped

We then matched census-block groups within the income groups by population density and percentage of minority representation

One matched block group per income level was randomly selected

Prevalence of Obesity in

Block-Groups

0

5

10

15

20

25

30

35

40

45

50

Ag

e-a

dju

sted

Ob

esit

y P

rev

ale

nce

(

)

High-Income Low-Income

Age-standardized to the 1990 US Census

Density of Environmental Factors in the

Community Contributes to a ldquoToxicrdquo

Obesity Environment

0

2

4

6

8

10

12

14

16

18

Fast-food Convenience Store Bars

Den

sity

10

00

perso

ns

High-Income Low-Income

COMMUNITYrsquoS PERCEPTION OF SAFETY

0

5

10

15

20

25

30

35

40

Daytime Nighttime

Perc

en

t (

) F

eeli

ng

So

mew

hat

Safe

or

Un

safe

Low-Income High-Income

Percent Substandard (or worse) Housing

or Ground Conditions

of Residential Properties

0

10

20

30

Structural Grounds

Perc

en

t (

)

Low-Income High-Income

CONCLUSIONS

These data suggest that the higher

frequency of outlets providing

calorically-dense foods and alcohol may

contribute to greater obesity prevalence

in residents of low-income communities

More research is needed to thoroughly

document environmental determinants

of health and obesity

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

From 1994-1998 HUD randomly assigned

4498 women with children living in public

housing in high-poverty urban census

tracts to one of three groups (1) housing

vouchers redeemable only if they moved

to a low-poverty census tract (2)

unrestricted vouchers or (3) control group

(no vouchers)

Ludwig et al NEJM 201136516

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

10-12 year follow-up showed modest but

potentially important reductions in the

prevalence of extreme obesity amp diabetes in the

group moving from a neighborhood with high

poverty on one of low poverty compared to the

control group

No differences between the group receiving

traditional vouchers amp the control group

ldquoNeighborhoods matterrdquo

Ludwig et al NEJM 201136516

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance traffic safety in areas where

persons are or could be physically active

--Community-scale urban design amp land use policies to

promote physical activity including design components

to improve street lighting infrastructure projects to

increase safety of pedestrian street crossing and use of

traffic calming approaches such as speed humps amp

traffic circles are effective in increasing physical activity

--Both community-scale amp street-scale policies amp practices

are effective in increasing physical activity

Recommended Community Strategies Encourage Communities to Organize for Change

Participate in community coalitions or

partnerships to address obesity

--Little evidence is available to determine the

impact of community coalitions on obesity

prevention

--The presence of anti-smoking community

coalitions has been associated with lower rates

of tobacco consumption

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

$103 million awarded to 61 states and

communities including state amp local government

agencies tribes amp territories amp state amp local non-

profit organizations

To build capacity to implement changes for

community prevention efforts to ensure long-

term success

To implement evidence-based and practice-

based programs to improve health amp wellness

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Priority areas are

Tobacco-free living

Active living and healthy eating

Evidence-based quality clinical and other

preventive health services for prevention

and control of high blood pressure and

high cholesterol

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Applicants proposed specific activities in

line with their chosen priority areas in their

applications

Grantee activities will not be finalized until

plans are negotiated with CDC by early

2012

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Capacity-Building Award

The Confederated Tribes of The Chehalis

Reservation is receiving a $498663 planning

award to build capacity to support healthy

lifestyles among their tribal population of 1500

in Washington State

Work will target tobacco-free living active living

and healthy eating and quality clinical and other

healthy serviceswwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Implementation Award

Austin TX Dept of Health and Human Services

is receiving $1026158 to serve Travis County

(Austin) to expand efforts in tobacco-free living

active living and healthy eating quality clinical

and other preventive services social and

emotional wellness and healthy and safe

physical environmentswwwcdcgov1052011

Building sustainable healthy

communities Bottom line

Obesity is an environmental problem

Despite progress in genetic research public health advances only will occur when we take the environment seriously

Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment

Until we do this we will not make substantial progress in addressing the epidemic of obesity

Poston amp Foreyt Atherosclerosis 1999

Whatrsquos the best approach

Integrate all sectors of society into community

change interventions

Incorporate

Science amp Technology

Education

FamilyCommunity

Healthcare

Arts amp Entertainment

Law amp Politics

Commerce amp Trade

Sectors of Society

Arts amp Entertainm

ent

Commerce amp Trade

Education

FamilyCommunity

Healthcare

Law amp Politics

Science amp Technology

Project FIT rationale design and baseline characteristics of a school- and community-

based intervention to address physical activity and healthy eating among low-income

elementary school children

Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D

Oh HJ Orth J Randall S Mayfield K Holmes D

Source

Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu

Abstract

BACKGROUND

This paper describes Project FIT a collaboration between the public school system local

health systems physicians neighborhood associations businesses faith-based leaders

community agencies and university researchers to develop a multi-faceted approach to

promote physical activity and healthy eating toward the general goal of preventing and

reducing childhood obesity among children in Grand Rapids MI USA

METHODSDESIGN

There are four overall components to Project FIT school community social marketing and

school staff wellness - all that focus on 1) increasing access to safe and affordable physical

activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)

improving the affordability and availability of nutritious food in the neighborhoods surrounding

the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding

nutrition and physical activity among school staff parents and students 4) impacting the

culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging

dialogue among all community partners to leverage existing programs and introduce new

ones

Rationale for community-based interventions

bull Increases in obesity prevalence due to genes

bull Increased calories (eg 200 Kcalday

over 10 years)

bull Increased portion sizes (eg 22 oz

steaks and 44 oz sodas)

bull Western diets in developing nations

increase risk of obesity

READINESS TO CHANGE

ldquoHabit is habit and not to be

flung out of the window but

coaxed downstairs a step at a

timerdquo

Mark Twain

Long-Term Weight Maintenance

National Weight Control Registry (N=10000)

Survey of 3000 members who have been in the

Registry for at least 10 years

Starting weight = 224 lbs Average weight loss=69

lbs

At 5 years participants had maintained an average

weight loss=52 lbs

At 10 years participants had maintained an average

weight loss=51 lbs

Thomas Bond Phelan et al TOS 2011

Long-Term Weight Maintenance

Weight Maintainers report that they usually

Track their food intake

Count calories or fat grams

Follow a low-calorie low fat diet (1800 caloriesday

less than 30 of calories from fat

Eat breakfast regularly

Limit the amount they eat out (about 3 timesweek

eat fast food less than onceweek)

Thomas Bond Phelan et al TOS 2011

Long-Term Weight Maintenance

Weight Maintainers report that they usually

Eat similar food regularly

Donrsquot splurge much on holidays amp special occasions

Walk about one hourday

Watch less than 10 hours of TV a week

Weigh themselves at least once a week

Thomas Bond Phelan et al TOS 2011

LONG-TERM WEIGHT MAINTENANCE

Continued consumption of a low-

calorie diet with moderate fat intake

Limited fast food

High levels of physical activity

Phalen et al Obesity 2006 14 710-716

LONG-TERM WEIGHT MAINTENANCE

Daily weighing improved

maintenance of weight loss

particularly when delivered

face to face

Wing et al NEJM 2006 3551563-1571

Most Promising Strategies For

Preventing Weight Regain

Providing multi-component

programs with ongoing

professional contacts

Physical activityexercise

Portion controlmeal replacements

Extending treatment through

weekly or bi-weekly sessions

Pharmacotherapy

Perri Foreyt amp Anton Preventing Weight Regain After Weight Loss 2008

Most Promising Strategies For

Preventing Weight Regain

Extended treatments have shown

promise in promoting adherence to

the behaviors required for the long-

term maintenance of weight loss

Continuous care approach focused

on reasonable long-term objectives

appears appropriate for most

patients

Perri Foreyt amp Anton Preventing Weight Regain After Weight

Loss 2008

An Example of a successful long-term

intervention

The Look AHEAD Study

Does Weight Loss Reduce

Cardiovascular Disease and Death in

Overweight Individuals with Diabetes

bull Action for HEAlth in Diabetes

bull Objective to examine in overweight

persons with Type 2 Diabetes the long-

term effects of an intensive lifestyle

intervention program compared to

diabetes education and support

bull 16 Centers

bull 5145 overweight volunteers with

diabetes

Look AHEAD

Look AHEAD

Primary End Point Composite

bull Cardiovascular death (including fatal

myocardial infarction and stroke)

bull Non-fatal myocardial infarction

bull Non-fatal stroke

Winston-Salem

Baltimore

Philadelphia

New York

Providence

Boston

Clinical Site Coordinating Center

Clinical Sites

Seattle

Los Angeles

San AntonioHouston

Baton Rouge

Minneapolis

Memphis

Birmingham

Pittsburgh

Denver

Phoenix

Look AHEADParticipants

101100Baseline weight (kg)

589586Age (years)

9496Attended 1 year exam

360359Baseline BMI

1514Insulin Users

3737Minority

6059Women

(N=2574)(N=2630)

DSELifestyle

p lt 0004

Look AHEAD

Study Interventions

bull Diabetes support and education - DSE (control group)

bull Lifestyle intervention ndash ILI (treatment group)

Look AHEAD

Lifestyle Intervention

Goals

bull 7 weight loss for the group (10

for individual)

bull 175 minutes of moderate intensity

activity

Look AHEAD

Lifestyle Intervention

bull Diet

ndash ADA NCEP (lt 30 fat lt 10 sat fat

gt15 protein)

ndash 1200-1500 (if weight lt250lbs)

ndash 1500-1800 (if weight gt250lbs)

ndash During first 4 weeks to 4 months portion

control (liquid meal replacements or

structured meal plan)

Look AHEAD

Lifestyle Intervention

bull Physical Activity

ndash unsupervised

ndash 175 minutes moderate intensityweek

ndash 5 daysweek

ndash walking

Weight Loss at 1-Year

-9

ILI 0

-1

-2

-3

-4

-5

-6

-7

-8

DSE

p lt 00001

W

eig

ht

Chan

ge

86

07

The Look AHEAD Research Group Diabetes Care 2007

Reduction in Initial Weight by Gender

N=872

N=1229N=1197

N=830

-12

-10

-8

-6

-4

-2

0

0 2 4 6 8 10 12

Months

R

ed

uctio

n in

In

itia

l W

eig

ht

Men

Women

Plt0001

The Look AHEAD Research Group Diabetes Care 2007

Fitness Change () at 1-Year

0

5

10

15

20

25

Mean

Fitness C

hange

Unadjusted

Plt0001Adjusted for 1 Year

Weight Change Plt0001

58

209

108

159

DSE ILI ILIDSE

The Look AHEAD Research Group Diabetes Care 2007

1-Year Changes in Markers of

Diabetes Control

Markers of Diabetes

Control ILI DSE P-value

Hemoglobin A1c () BL

Hemoglobin A1c () Y1

Y1 ndash Baseline

725

661

-064

729

715

-014

026

lt0001

lt0001

Fasting glucose (mgdl) BL

Fasting glucose (mgdl) Y1

Y1 ndash Baseline

1519

1304

-215

1536

1464

-72

021

lt0001

lt0001

Diabetes medications BL

Diabetes medications Y1

Y1 ndash Baseline

865

786

-78

865

887

22

093

lt0001

lt0001

1-Year Changes in Markers of

Blood Pressure ControlMarkers of Blood Pressure

Control ILI DSE P-value

Systolic BP (mmHg) BL

Systolic BP (mmHg) Y1

Y1 ndash Baseline

1282

1214

-68

1294

1266

-28

026

lt0001

lt0001

Diastolic BP (mmHg) BL

Diastolic BP (mmHg) Y1

Y1 ndash Baseline

699

670

-30

704

686

-18

011

lt0001

lt0001

Antihypertensive medications BL

Antihypertensive medications Y1

Y1 ndash Baseline

753

752

-01

737

759

22

023

054

002

1-Year Changes in Markers of Lipid

Control

Markers of Lipid Control ILI DSE P-value

LDL-cholesterol (mgdl) BL

LDL-cholesterol (mgdl) Y1

Y1 ndash Baseline

1122

1070

-52

1124

1067

-57

078

074

049

HDL-cholesterol (mgdl) BL

HDL-cholesterol (mgdl) Y1

Y1 ndash Baseline

435

469

34

436

449

14

080

lt0001

lt0001

Triglycerides (mgdl) BL

Triglycerides (mgdl) Y1

Y1 ndash Baseline

1828

1525

-303

1800

1654

-146

038

lt0001

lt0001

Lipid lowering medications BL

Lipid lowering medications Y1

Y1 ndash Baseline

494

530

37

484

578

94

052

lt0001

lt0001

1-Year Changes in Percent of Participants

Meeting ADA Goals

ADA Goal ILI DSE P-value

Hemoglobin A1c lt 7 BL

Hemoglobin A1c lt 7 Y1

Y1 ndash Baseline

463

727

264

454

508

54

050

lt0001

lt0001

Blood pressure lt 13080 mmHg BL

Blood pressure lt 13080 mmHg Y1

Y1 ndash Baseline

535

686

151

499

570

70

001

lt0001

lt0001

LDL-cholesterol lt 100 mgdl BL

LDL-cholesterol lt 100 mgdl Y1

Y1 ndash Baseline

371

438

67

369

449

80

087

045

034

All three goals BL

All three goals Y1

Y1 ndash Baseline

108

236

128

95

160

65

013

lt0001

lt0001

Mean Changes in Weight Fitness amp BP

Averaged Over Four Years

DSE

Mean

ILI

Mean

P-value

Weight Loss

( initial wt)

-088 -615 lt 00001

Fitness

( METS)

196 1274 lt00001

HbA1c -009 -036 lt 00001

SBP (mm Hg) -297 -533 lt 00001

DBP (mm Hg) -248 -292 0012

Look AHEAD Research Group Arch Int Med 2010

Mean Changes in Lipid Profile

Averaged Over Four Years

DSE

Mean

ILI

Mean

P-value

HDL (mgdl) 197 367 lt00001

TG (mgdl) -1975 -2556 00006

LDL (mgdl) -1284 -1127 0009

LDL (mgdl)

(Adjusting for

medication use)

-922 -875 042

Look AHEAD Research Group Arch Int Med 2010

Percent () Completing Outcome

Measures at Years 1-4

Intervention Group

(ILI)

Year 1 971

Year 2 949

Year 3 940

Year 4 941

Comparison Group

(DSE)

Year 1 957

Year 2 935

Year 3 938

Year 4 931

Look AHEAD Summary

ILI had significantly greater improvements than DSE in all CVD risk factors averaged across 4 years (except LDL-C)

There may be long-term beneficial effects from this 4-year period in which ILI subjects have been exposed to lower CVD risk factors

Longer follow-ups will determine whether these lowered CVD risk factors can be maintained amp whether lifestyle intervention has positive effects on CVD morbidity amp mortality

Mary J

Female

White

56 years old at start of Look AHEAD

study

Past Medical History Type 2 diabetes

overweight diverticulosis arthritis

sleep apnea back pain

Mary J

bullLong term strugglesbull Helping youngest daughter with

personal issues and children

bull Rotator cuff problems

bull Degenerative disks in back

bull Rheumatoid arthritis

bull Diabetes

bull Physically demanding job

bull Financial struggles

Pounds

Years

82007 grandkids enter pre-school

Catherine L

Female

White

47 years old at start of Look AHEAD

study

Past Medical History Type 2 diabetes

overweight high blood pressure

hypothyroidism back pain

Catherine L

Long term struggles

bull Motherrsquos declining health and death

bull Multiple serious injuries

bull Sudden death of sister

bull Death of step-father

bull Declining economy

bull Children living at home

Pounds

Years

Realistic Management Goals

5-10 weight loss

Health energy and fitness

Well-being and self-esteem

Mood and appearance

Functional and recreational

activity

Key Elements

Focus on health and energy

Food and physical activity diaries

Gradual increase in physical activity

Gradual reduction in dietary fat

No feelings of food deprivation

Social support groups

Recommended Strategies for Building

Sustainable Healthy Communities

Overview from USA

Promote the availability of affordable healthy

food and beverages

Support healthy food and beverage choices

Encourage breastfeeding

Encourage physical activity or limit sedentary

activity among children amp youth

Create safe communities that support physical

activity

Encourage communities to organize for change

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Increase the availability of healthier food and

beverage choices in public service venues (eg

schools city amp county buildings etc)

--Insufficient evidence in school-based programs

--Associations suggest availability amp increased

consumption

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve availability of affordable healthier

food amp beverage choices in public service

venues

--Reducing the cost of healthier foods

increases their purchase

--Providing coupons redeemable for

healthier foods increases their purchase

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve geographic availability of

supermarkets in underserved areas

-- Greater access to nearby supermarkets is

associated with healthier eating behaviors

-- Increasing the number of supermarkets in

underserved neighborhoods increased

real estate values increased economic

activity amp employment amp resulted in lower

food prices

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Provide incentives to food retailers to locate in

andor offer healthier food choices in

underserved areas

-- Presence of retail venues that provide healthier

foods is associated with better nutrition

-- Greater availability of supermarkets was

associated with lower adolescent BMI scores

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Improve availability of mechanisms for

purchasing foods from farms

--Evidence supporting a direct link between

purchasing food from farms amp improved diet is

limited

--Two studies of initiatives to encourage

participation in farmersrsquo market showed

increased intention to eat more fruits amp

vegetables but no direct evidence

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Provide incentives for the production

distribution and procurement of foods from local

farms

--No evidence has been published to link local

food production amp health outcomes

--There is a current study exploring the potential

nutritional amp health benefits of eating locally

grown foods

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Restrict availability of less healthy foods amp

beverages in public service venues

--No peer-reviewed studies examined the impact

designed to restrict availability of less healthy

foods in public service venues

--21 states have policies that restrict the sale of

competitive foods in schools beyond USDA

regulations however no studies have evaluated

the impact of the policies

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Institute smaller portion size options in public

service venues

--Evidence is lacking to demonstrate effectiveness

of population-based interventions aimed at

reducing portion sizes in public service venues

--Evidence from clinical studies in laboratories

demonstrates decreasing portion sizes

decreases energy intake

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Limit advertisements of less healthy foods amp

beverages

--Little evidence is available regarding the impact

of restricting advertising on purchasing amp

consumption of less healthy foods

--Cross-sectional time-series studies of tobacco-

control efforts suggest an association between

advertising bans amp decreased tobacco

consumption

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Discourage consumption of sugar-sweetened

beverages

--One longitudinal study of a school-based

intervention among Native-American high school

students showed a substantial reduction in

sugar-sweetened beverages over a 3-year

period

--A RCT of a home-based intervention that

eliminated sugar-sweetened beverages showed

reduction in BMI scores

Recommended Community Strategies Strategies to encourage breastfeeding

Increase support for breastfeeding

--Evidence directly linking environmental

interventions that support breastfeeding with

obesity-related outcomes is lacking

--Epidemiologic studies indicate that breastfeeding

helps prevent pediatric obesity

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Require physical education in schools

--14 studies have demonstrated that school-based

PE was effective in increasing levels of physical

activity and improving physical fitness

--Minimum of 150 minwk in elementary schools

225 minwk in middle schools and high schools

throughout the school year as recommended by

NASPE

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Increase opportunities for extracurricular

physical activity

--Participation in after-school programs increased

studentsrsquo level of physical activity amp improved

obesity-related outcomes (improved CV fitness

reduced body fat)

--2 pilot studies providing extracurricular physical

activity showed increased levels of PA amp

decreased sedentary behavior

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Reduce screen time in public service venues

--A school-based RCT indicated that children who

reduced their television videotape amp video

game use had significant decrease in BMI tricep

skin fold thickness amp waist circumference

compared to controls

--Spending less time watching television is

associated with increased physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Improve access to outdoor recreational

facilities

--Review of 108 studies indicated that access to facilities

and programs for recreation near their homes amp time

spent outdoors correlated positively with increased

physical activity among childrenamp adults

--Perceptions that footpaths are safe for walking was

significantly associated with adults being classified as

physically active at a level sufficient for health benefits

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting

bicycling

--Longitudinal intervention studies have

demonstrated that improving bicycling

infrastructure is associated with increased

frequency of bicycling

--Cross-sectional studies indicated a significant

association between bicycling infrastructure amp

frequency of biking

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting walking

--Reviews of cross-sectional studies of

environmental correlates of physical activity amp

walking generally find a positive association

between infrastructure supportive of walking amp

physical activity

--Identifying amp creating safe routes to school

together with educational components

increased the number of students walking to

school

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Locating schools within easy walking

distance of residential areas

--Community-scale urban design amp land use policies amp

practices including locating schools stores workplaces

amp recreation areas close to residential areas are

effective in facilitating an increase in levels of physical

activity

--Majority of efforts to encourage walking to school involve

improving the routes rather than improving the location

of schools

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Improve access to public transportation

--Insufficient evidence exists to determine

effectiveness of transportation policies in

increasing the level of physical activity or

improving fitness

--1 study indicated that 29 of individuals who

walk to and from public transit achieve at least

30 minutes of daily physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Zone for mixed-use development

--Allows residential commercial institutional amp

other public land uses to be located in close

proximity to one another

--Studies using correlation analyses amp regression

models indicated that mixed land use was

associated with increased walking amp cycling

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance personal safety in areas where

persons are or could be physically active

--Cross-sectional studies have demonstrated a

negative relationship between crime rates andor

perceived safety amp physical activity in

neighborhoods

--Few intervention studies have evaluated the

impact of policies amp practices to improve

personal safety on physical activity

Geospatial Mapping Linking Urban

Environments to Health Risk

Measure association between environmental variables amp health risk factors

Assess relationships between variables at different levels of analysis

Used in conjunction with linear analyses

Our Community Environmental Model

of Obesity

Community Factors

Poverty

Crime

Grocery Quality

Restaurants

Parks

Sidewalks

Fast Food Outlets

Recreational

Facilities

Individual Factors

Dietary Intake

Physical Activity

Genetics

Family History

StressCoping

Eating Disorders

Psychological

Problems

Weight

Status

Chosen Neighborhoods

Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped

We then matched census-block groups within the income groups by population density and percentage of minority representation

One matched block group per income level was randomly selected

Prevalence of Obesity in

Block-Groups

0

5

10

15

20

25

30

35

40

45

50

Ag

e-a

dju

sted

Ob

esit

y P

rev

ale

nce

(

)

High-Income Low-Income

Age-standardized to the 1990 US Census

Density of Environmental Factors in the

Community Contributes to a ldquoToxicrdquo

Obesity Environment

0

2

4

6

8

10

12

14

16

18

Fast-food Convenience Store Bars

Den

sity

10

00

perso

ns

High-Income Low-Income

COMMUNITYrsquoS PERCEPTION OF SAFETY

0

5

10

15

20

25

30

35

40

Daytime Nighttime

Perc

en

t (

) F

eeli

ng

So

mew

hat

Safe

or

Un

safe

Low-Income High-Income

Percent Substandard (or worse) Housing

or Ground Conditions

of Residential Properties

0

10

20

30

Structural Grounds

Perc

en

t (

)

Low-Income High-Income

CONCLUSIONS

These data suggest that the higher

frequency of outlets providing

calorically-dense foods and alcohol may

contribute to greater obesity prevalence

in residents of low-income communities

More research is needed to thoroughly

document environmental determinants

of health and obesity

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

From 1994-1998 HUD randomly assigned

4498 women with children living in public

housing in high-poverty urban census

tracts to one of three groups (1) housing

vouchers redeemable only if they moved

to a low-poverty census tract (2)

unrestricted vouchers or (3) control group

(no vouchers)

Ludwig et al NEJM 201136516

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

10-12 year follow-up showed modest but

potentially important reductions in the

prevalence of extreme obesity amp diabetes in the

group moving from a neighborhood with high

poverty on one of low poverty compared to the

control group

No differences between the group receiving

traditional vouchers amp the control group

ldquoNeighborhoods matterrdquo

Ludwig et al NEJM 201136516

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance traffic safety in areas where

persons are or could be physically active

--Community-scale urban design amp land use policies to

promote physical activity including design components

to improve street lighting infrastructure projects to

increase safety of pedestrian street crossing and use of

traffic calming approaches such as speed humps amp

traffic circles are effective in increasing physical activity

--Both community-scale amp street-scale policies amp practices

are effective in increasing physical activity

Recommended Community Strategies Encourage Communities to Organize for Change

Participate in community coalitions or

partnerships to address obesity

--Little evidence is available to determine the

impact of community coalitions on obesity

prevention

--The presence of anti-smoking community

coalitions has been associated with lower rates

of tobacco consumption

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

$103 million awarded to 61 states and

communities including state amp local government

agencies tribes amp territories amp state amp local non-

profit organizations

To build capacity to implement changes for

community prevention efforts to ensure long-

term success

To implement evidence-based and practice-

based programs to improve health amp wellness

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Priority areas are

Tobacco-free living

Active living and healthy eating

Evidence-based quality clinical and other

preventive health services for prevention

and control of high blood pressure and

high cholesterol

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Applicants proposed specific activities in

line with their chosen priority areas in their

applications

Grantee activities will not be finalized until

plans are negotiated with CDC by early

2012

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Capacity-Building Award

The Confederated Tribes of The Chehalis

Reservation is receiving a $498663 planning

award to build capacity to support healthy

lifestyles among their tribal population of 1500

in Washington State

Work will target tobacco-free living active living

and healthy eating and quality clinical and other

healthy serviceswwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Implementation Award

Austin TX Dept of Health and Human Services

is receiving $1026158 to serve Travis County

(Austin) to expand efforts in tobacco-free living

active living and healthy eating quality clinical

and other preventive services social and

emotional wellness and healthy and safe

physical environmentswwwcdcgov1052011

Building sustainable healthy

communities Bottom line

Obesity is an environmental problem

Despite progress in genetic research public health advances only will occur when we take the environment seriously

Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment

Until we do this we will not make substantial progress in addressing the epidemic of obesity

Poston amp Foreyt Atherosclerosis 1999

Whatrsquos the best approach

Integrate all sectors of society into community

change interventions

Incorporate

Science amp Technology

Education

FamilyCommunity

Healthcare

Arts amp Entertainment

Law amp Politics

Commerce amp Trade

Sectors of Society

Arts amp Entertainm

ent

Commerce amp Trade

Education

FamilyCommunity

Healthcare

Law amp Politics

Science amp Technology

Project FIT rationale design and baseline characteristics of a school- and community-

based intervention to address physical activity and healthy eating among low-income

elementary school children

Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D

Oh HJ Orth J Randall S Mayfield K Holmes D

Source

Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu

Abstract

BACKGROUND

This paper describes Project FIT a collaboration between the public school system local

health systems physicians neighborhood associations businesses faith-based leaders

community agencies and university researchers to develop a multi-faceted approach to

promote physical activity and healthy eating toward the general goal of preventing and

reducing childhood obesity among children in Grand Rapids MI USA

METHODSDESIGN

There are four overall components to Project FIT school community social marketing and

school staff wellness - all that focus on 1) increasing access to safe and affordable physical

activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)

improving the affordability and availability of nutritious food in the neighborhoods surrounding

the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding

nutrition and physical activity among school staff parents and students 4) impacting the

culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging

dialogue among all community partners to leverage existing programs and introduce new

ones

READINESS TO CHANGE

ldquoHabit is habit and not to be

flung out of the window but

coaxed downstairs a step at a

timerdquo

Mark Twain

Long-Term Weight Maintenance

National Weight Control Registry (N=10000)

Survey of 3000 members who have been in the

Registry for at least 10 years

Starting weight = 224 lbs Average weight loss=69

lbs

At 5 years participants had maintained an average

weight loss=52 lbs

At 10 years participants had maintained an average

weight loss=51 lbs

Thomas Bond Phelan et al TOS 2011

Long-Term Weight Maintenance

Weight Maintainers report that they usually

Track their food intake

Count calories or fat grams

Follow a low-calorie low fat diet (1800 caloriesday

less than 30 of calories from fat

Eat breakfast regularly

Limit the amount they eat out (about 3 timesweek

eat fast food less than onceweek)

Thomas Bond Phelan et al TOS 2011

Long-Term Weight Maintenance

Weight Maintainers report that they usually

Eat similar food regularly

Donrsquot splurge much on holidays amp special occasions

Walk about one hourday

Watch less than 10 hours of TV a week

Weigh themselves at least once a week

Thomas Bond Phelan et al TOS 2011

LONG-TERM WEIGHT MAINTENANCE

Continued consumption of a low-

calorie diet with moderate fat intake

Limited fast food

High levels of physical activity

Phalen et al Obesity 2006 14 710-716

LONG-TERM WEIGHT MAINTENANCE

Daily weighing improved

maintenance of weight loss

particularly when delivered

face to face

Wing et al NEJM 2006 3551563-1571

Most Promising Strategies For

Preventing Weight Regain

Providing multi-component

programs with ongoing

professional contacts

Physical activityexercise

Portion controlmeal replacements

Extending treatment through

weekly or bi-weekly sessions

Pharmacotherapy

Perri Foreyt amp Anton Preventing Weight Regain After Weight Loss 2008

Most Promising Strategies For

Preventing Weight Regain

Extended treatments have shown

promise in promoting adherence to

the behaviors required for the long-

term maintenance of weight loss

Continuous care approach focused

on reasonable long-term objectives

appears appropriate for most

patients

Perri Foreyt amp Anton Preventing Weight Regain After Weight

Loss 2008

An Example of a successful long-term

intervention

The Look AHEAD Study

Does Weight Loss Reduce

Cardiovascular Disease and Death in

Overweight Individuals with Diabetes

bull Action for HEAlth in Diabetes

bull Objective to examine in overweight

persons with Type 2 Diabetes the long-

term effects of an intensive lifestyle

intervention program compared to

diabetes education and support

bull 16 Centers

bull 5145 overweight volunteers with

diabetes

Look AHEAD

Look AHEAD

Primary End Point Composite

bull Cardiovascular death (including fatal

myocardial infarction and stroke)

bull Non-fatal myocardial infarction

bull Non-fatal stroke

Winston-Salem

Baltimore

Philadelphia

New York

Providence

Boston

Clinical Site Coordinating Center

Clinical Sites

Seattle

Los Angeles

San AntonioHouston

Baton Rouge

Minneapolis

Memphis

Birmingham

Pittsburgh

Denver

Phoenix

Look AHEADParticipants

101100Baseline weight (kg)

589586Age (years)

9496Attended 1 year exam

360359Baseline BMI

1514Insulin Users

3737Minority

6059Women

(N=2574)(N=2630)

DSELifestyle

p lt 0004

Look AHEAD

Study Interventions

bull Diabetes support and education - DSE (control group)

bull Lifestyle intervention ndash ILI (treatment group)

Look AHEAD

Lifestyle Intervention

Goals

bull 7 weight loss for the group (10

for individual)

bull 175 minutes of moderate intensity

activity

Look AHEAD

Lifestyle Intervention

bull Diet

ndash ADA NCEP (lt 30 fat lt 10 sat fat

gt15 protein)

ndash 1200-1500 (if weight lt250lbs)

ndash 1500-1800 (if weight gt250lbs)

ndash During first 4 weeks to 4 months portion

control (liquid meal replacements or

structured meal plan)

Look AHEAD

Lifestyle Intervention

bull Physical Activity

ndash unsupervised

ndash 175 minutes moderate intensityweek

ndash 5 daysweek

ndash walking

Weight Loss at 1-Year

-9

ILI 0

-1

-2

-3

-4

-5

-6

-7

-8

DSE

p lt 00001

W

eig

ht

Chan

ge

86

07

The Look AHEAD Research Group Diabetes Care 2007

Reduction in Initial Weight by Gender

N=872

N=1229N=1197

N=830

-12

-10

-8

-6

-4

-2

0

0 2 4 6 8 10 12

Months

R

ed

uctio

n in

In

itia

l W

eig

ht

Men

Women

Plt0001

The Look AHEAD Research Group Diabetes Care 2007

Fitness Change () at 1-Year

0

5

10

15

20

25

Mean

Fitness C

hange

Unadjusted

Plt0001Adjusted for 1 Year

Weight Change Plt0001

58

209

108

159

DSE ILI ILIDSE

The Look AHEAD Research Group Diabetes Care 2007

1-Year Changes in Markers of

Diabetes Control

Markers of Diabetes

Control ILI DSE P-value

Hemoglobin A1c () BL

Hemoglobin A1c () Y1

Y1 ndash Baseline

725

661

-064

729

715

-014

026

lt0001

lt0001

Fasting glucose (mgdl) BL

Fasting glucose (mgdl) Y1

Y1 ndash Baseline

1519

1304

-215

1536

1464

-72

021

lt0001

lt0001

Diabetes medications BL

Diabetes medications Y1

Y1 ndash Baseline

865

786

-78

865

887

22

093

lt0001

lt0001

1-Year Changes in Markers of

Blood Pressure ControlMarkers of Blood Pressure

Control ILI DSE P-value

Systolic BP (mmHg) BL

Systolic BP (mmHg) Y1

Y1 ndash Baseline

1282

1214

-68

1294

1266

-28

026

lt0001

lt0001

Diastolic BP (mmHg) BL

Diastolic BP (mmHg) Y1

Y1 ndash Baseline

699

670

-30

704

686

-18

011

lt0001

lt0001

Antihypertensive medications BL

Antihypertensive medications Y1

Y1 ndash Baseline

753

752

-01

737

759

22

023

054

002

1-Year Changes in Markers of Lipid

Control

Markers of Lipid Control ILI DSE P-value

LDL-cholesterol (mgdl) BL

LDL-cholesterol (mgdl) Y1

Y1 ndash Baseline

1122

1070

-52

1124

1067

-57

078

074

049

HDL-cholesterol (mgdl) BL

HDL-cholesterol (mgdl) Y1

Y1 ndash Baseline

435

469

34

436

449

14

080

lt0001

lt0001

Triglycerides (mgdl) BL

Triglycerides (mgdl) Y1

Y1 ndash Baseline

1828

1525

-303

1800

1654

-146

038

lt0001

lt0001

Lipid lowering medications BL

Lipid lowering medications Y1

Y1 ndash Baseline

494

530

37

484

578

94

052

lt0001

lt0001

1-Year Changes in Percent of Participants

Meeting ADA Goals

ADA Goal ILI DSE P-value

Hemoglobin A1c lt 7 BL

Hemoglobin A1c lt 7 Y1

Y1 ndash Baseline

463

727

264

454

508

54

050

lt0001

lt0001

Blood pressure lt 13080 mmHg BL

Blood pressure lt 13080 mmHg Y1

Y1 ndash Baseline

535

686

151

499

570

70

001

lt0001

lt0001

LDL-cholesterol lt 100 mgdl BL

LDL-cholesterol lt 100 mgdl Y1

Y1 ndash Baseline

371

438

67

369

449

80

087

045

034

All three goals BL

All three goals Y1

Y1 ndash Baseline

108

236

128

95

160

65

013

lt0001

lt0001

Mean Changes in Weight Fitness amp BP

Averaged Over Four Years

DSE

Mean

ILI

Mean

P-value

Weight Loss

( initial wt)

-088 -615 lt 00001

Fitness

( METS)

196 1274 lt00001

HbA1c -009 -036 lt 00001

SBP (mm Hg) -297 -533 lt 00001

DBP (mm Hg) -248 -292 0012

Look AHEAD Research Group Arch Int Med 2010

Mean Changes in Lipid Profile

Averaged Over Four Years

DSE

Mean

ILI

Mean

P-value

HDL (mgdl) 197 367 lt00001

TG (mgdl) -1975 -2556 00006

LDL (mgdl) -1284 -1127 0009

LDL (mgdl)

(Adjusting for

medication use)

-922 -875 042

Look AHEAD Research Group Arch Int Med 2010

Percent () Completing Outcome

Measures at Years 1-4

Intervention Group

(ILI)

Year 1 971

Year 2 949

Year 3 940

Year 4 941

Comparison Group

(DSE)

Year 1 957

Year 2 935

Year 3 938

Year 4 931

Look AHEAD Summary

ILI had significantly greater improvements than DSE in all CVD risk factors averaged across 4 years (except LDL-C)

There may be long-term beneficial effects from this 4-year period in which ILI subjects have been exposed to lower CVD risk factors

Longer follow-ups will determine whether these lowered CVD risk factors can be maintained amp whether lifestyle intervention has positive effects on CVD morbidity amp mortality

Mary J

Female

White

56 years old at start of Look AHEAD

study

Past Medical History Type 2 diabetes

overweight diverticulosis arthritis

sleep apnea back pain

Mary J

bullLong term strugglesbull Helping youngest daughter with

personal issues and children

bull Rotator cuff problems

bull Degenerative disks in back

bull Rheumatoid arthritis

bull Diabetes

bull Physically demanding job

bull Financial struggles

Pounds

Years

82007 grandkids enter pre-school

Catherine L

Female

White

47 years old at start of Look AHEAD

study

Past Medical History Type 2 diabetes

overweight high blood pressure

hypothyroidism back pain

Catherine L

Long term struggles

bull Motherrsquos declining health and death

bull Multiple serious injuries

bull Sudden death of sister

bull Death of step-father

bull Declining economy

bull Children living at home

Pounds

Years

Realistic Management Goals

5-10 weight loss

Health energy and fitness

Well-being and self-esteem

Mood and appearance

Functional and recreational

activity

Key Elements

Focus on health and energy

Food and physical activity diaries

Gradual increase in physical activity

Gradual reduction in dietary fat

No feelings of food deprivation

Social support groups

Recommended Strategies for Building

Sustainable Healthy Communities

Overview from USA

Promote the availability of affordable healthy

food and beverages

Support healthy food and beverage choices

Encourage breastfeeding

Encourage physical activity or limit sedentary

activity among children amp youth

Create safe communities that support physical

activity

Encourage communities to organize for change

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Increase the availability of healthier food and

beverage choices in public service venues (eg

schools city amp county buildings etc)

--Insufficient evidence in school-based programs

--Associations suggest availability amp increased

consumption

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve availability of affordable healthier

food amp beverage choices in public service

venues

--Reducing the cost of healthier foods

increases their purchase

--Providing coupons redeemable for

healthier foods increases their purchase

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve geographic availability of

supermarkets in underserved areas

-- Greater access to nearby supermarkets is

associated with healthier eating behaviors

-- Increasing the number of supermarkets in

underserved neighborhoods increased

real estate values increased economic

activity amp employment amp resulted in lower

food prices

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Provide incentives to food retailers to locate in

andor offer healthier food choices in

underserved areas

-- Presence of retail venues that provide healthier

foods is associated with better nutrition

-- Greater availability of supermarkets was

associated with lower adolescent BMI scores

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Improve availability of mechanisms for

purchasing foods from farms

--Evidence supporting a direct link between

purchasing food from farms amp improved diet is

limited

--Two studies of initiatives to encourage

participation in farmersrsquo market showed

increased intention to eat more fruits amp

vegetables but no direct evidence

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Provide incentives for the production

distribution and procurement of foods from local

farms

--No evidence has been published to link local

food production amp health outcomes

--There is a current study exploring the potential

nutritional amp health benefits of eating locally

grown foods

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Restrict availability of less healthy foods amp

beverages in public service venues

--No peer-reviewed studies examined the impact

designed to restrict availability of less healthy

foods in public service venues

--21 states have policies that restrict the sale of

competitive foods in schools beyond USDA

regulations however no studies have evaluated

the impact of the policies

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Institute smaller portion size options in public

service venues

--Evidence is lacking to demonstrate effectiveness

of population-based interventions aimed at

reducing portion sizes in public service venues

--Evidence from clinical studies in laboratories

demonstrates decreasing portion sizes

decreases energy intake

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Limit advertisements of less healthy foods amp

beverages

--Little evidence is available regarding the impact

of restricting advertising on purchasing amp

consumption of less healthy foods

--Cross-sectional time-series studies of tobacco-

control efforts suggest an association between

advertising bans amp decreased tobacco

consumption

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Discourage consumption of sugar-sweetened

beverages

--One longitudinal study of a school-based

intervention among Native-American high school

students showed a substantial reduction in

sugar-sweetened beverages over a 3-year

period

--A RCT of a home-based intervention that

eliminated sugar-sweetened beverages showed

reduction in BMI scores

Recommended Community Strategies Strategies to encourage breastfeeding

Increase support for breastfeeding

--Evidence directly linking environmental

interventions that support breastfeeding with

obesity-related outcomes is lacking

--Epidemiologic studies indicate that breastfeeding

helps prevent pediatric obesity

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Require physical education in schools

--14 studies have demonstrated that school-based

PE was effective in increasing levels of physical

activity and improving physical fitness

--Minimum of 150 minwk in elementary schools

225 minwk in middle schools and high schools

throughout the school year as recommended by

NASPE

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Increase opportunities for extracurricular

physical activity

--Participation in after-school programs increased

studentsrsquo level of physical activity amp improved

obesity-related outcomes (improved CV fitness

reduced body fat)

--2 pilot studies providing extracurricular physical

activity showed increased levels of PA amp

decreased sedentary behavior

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Reduce screen time in public service venues

--A school-based RCT indicated that children who

reduced their television videotape amp video

game use had significant decrease in BMI tricep

skin fold thickness amp waist circumference

compared to controls

--Spending less time watching television is

associated with increased physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Improve access to outdoor recreational

facilities

--Review of 108 studies indicated that access to facilities

and programs for recreation near their homes amp time

spent outdoors correlated positively with increased

physical activity among childrenamp adults

--Perceptions that footpaths are safe for walking was

significantly associated with adults being classified as

physically active at a level sufficient for health benefits

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting

bicycling

--Longitudinal intervention studies have

demonstrated that improving bicycling

infrastructure is associated with increased

frequency of bicycling

--Cross-sectional studies indicated a significant

association between bicycling infrastructure amp

frequency of biking

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting walking

--Reviews of cross-sectional studies of

environmental correlates of physical activity amp

walking generally find a positive association

between infrastructure supportive of walking amp

physical activity

--Identifying amp creating safe routes to school

together with educational components

increased the number of students walking to

school

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Locating schools within easy walking

distance of residential areas

--Community-scale urban design amp land use policies amp

practices including locating schools stores workplaces

amp recreation areas close to residential areas are

effective in facilitating an increase in levels of physical

activity

--Majority of efforts to encourage walking to school involve

improving the routes rather than improving the location

of schools

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Improve access to public transportation

--Insufficient evidence exists to determine

effectiveness of transportation policies in

increasing the level of physical activity or

improving fitness

--1 study indicated that 29 of individuals who

walk to and from public transit achieve at least

30 minutes of daily physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Zone for mixed-use development

--Allows residential commercial institutional amp

other public land uses to be located in close

proximity to one another

--Studies using correlation analyses amp regression

models indicated that mixed land use was

associated with increased walking amp cycling

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance personal safety in areas where

persons are or could be physically active

--Cross-sectional studies have demonstrated a

negative relationship between crime rates andor

perceived safety amp physical activity in

neighborhoods

--Few intervention studies have evaluated the

impact of policies amp practices to improve

personal safety on physical activity

Geospatial Mapping Linking Urban

Environments to Health Risk

Measure association between environmental variables amp health risk factors

Assess relationships between variables at different levels of analysis

Used in conjunction with linear analyses

Our Community Environmental Model

of Obesity

Community Factors

Poverty

Crime

Grocery Quality

Restaurants

Parks

Sidewalks

Fast Food Outlets

Recreational

Facilities

Individual Factors

Dietary Intake

Physical Activity

Genetics

Family History

StressCoping

Eating Disorders

Psychological

Problems

Weight

Status

Chosen Neighborhoods

Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped

We then matched census-block groups within the income groups by population density and percentage of minority representation

One matched block group per income level was randomly selected

Prevalence of Obesity in

Block-Groups

0

5

10

15

20

25

30

35

40

45

50

Ag

e-a

dju

sted

Ob

esit

y P

rev

ale

nce

(

)

High-Income Low-Income

Age-standardized to the 1990 US Census

Density of Environmental Factors in the

Community Contributes to a ldquoToxicrdquo

Obesity Environment

0

2

4

6

8

10

12

14

16

18

Fast-food Convenience Store Bars

Den

sity

10

00

perso

ns

High-Income Low-Income

COMMUNITYrsquoS PERCEPTION OF SAFETY

0

5

10

15

20

25

30

35

40

Daytime Nighttime

Perc

en

t (

) F

eeli

ng

So

mew

hat

Safe

or

Un

safe

Low-Income High-Income

Percent Substandard (or worse) Housing

or Ground Conditions

of Residential Properties

0

10

20

30

Structural Grounds

Perc

en

t (

)

Low-Income High-Income

CONCLUSIONS

These data suggest that the higher

frequency of outlets providing

calorically-dense foods and alcohol may

contribute to greater obesity prevalence

in residents of low-income communities

More research is needed to thoroughly

document environmental determinants

of health and obesity

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

From 1994-1998 HUD randomly assigned

4498 women with children living in public

housing in high-poverty urban census

tracts to one of three groups (1) housing

vouchers redeemable only if they moved

to a low-poverty census tract (2)

unrestricted vouchers or (3) control group

(no vouchers)

Ludwig et al NEJM 201136516

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

10-12 year follow-up showed modest but

potentially important reductions in the

prevalence of extreme obesity amp diabetes in the

group moving from a neighborhood with high

poverty on one of low poverty compared to the

control group

No differences between the group receiving

traditional vouchers amp the control group

ldquoNeighborhoods matterrdquo

Ludwig et al NEJM 201136516

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance traffic safety in areas where

persons are or could be physically active

--Community-scale urban design amp land use policies to

promote physical activity including design components

to improve street lighting infrastructure projects to

increase safety of pedestrian street crossing and use of

traffic calming approaches such as speed humps amp

traffic circles are effective in increasing physical activity

--Both community-scale amp street-scale policies amp practices

are effective in increasing physical activity

Recommended Community Strategies Encourage Communities to Organize for Change

Participate in community coalitions or

partnerships to address obesity

--Little evidence is available to determine the

impact of community coalitions on obesity

prevention

--The presence of anti-smoking community

coalitions has been associated with lower rates

of tobacco consumption

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

$103 million awarded to 61 states and

communities including state amp local government

agencies tribes amp territories amp state amp local non-

profit organizations

To build capacity to implement changes for

community prevention efforts to ensure long-

term success

To implement evidence-based and practice-

based programs to improve health amp wellness

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Priority areas are

Tobacco-free living

Active living and healthy eating

Evidence-based quality clinical and other

preventive health services for prevention

and control of high blood pressure and

high cholesterol

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Applicants proposed specific activities in

line with their chosen priority areas in their

applications

Grantee activities will not be finalized until

plans are negotiated with CDC by early

2012

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Capacity-Building Award

The Confederated Tribes of The Chehalis

Reservation is receiving a $498663 planning

award to build capacity to support healthy

lifestyles among their tribal population of 1500

in Washington State

Work will target tobacco-free living active living

and healthy eating and quality clinical and other

healthy serviceswwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Implementation Award

Austin TX Dept of Health and Human Services

is receiving $1026158 to serve Travis County

(Austin) to expand efforts in tobacco-free living

active living and healthy eating quality clinical

and other preventive services social and

emotional wellness and healthy and safe

physical environmentswwwcdcgov1052011

Building sustainable healthy

communities Bottom line

Obesity is an environmental problem

Despite progress in genetic research public health advances only will occur when we take the environment seriously

Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment

Until we do this we will not make substantial progress in addressing the epidemic of obesity

Poston amp Foreyt Atherosclerosis 1999

Whatrsquos the best approach

Integrate all sectors of society into community

change interventions

Incorporate

Science amp Technology

Education

FamilyCommunity

Healthcare

Arts amp Entertainment

Law amp Politics

Commerce amp Trade

Sectors of Society

Arts amp Entertainm

ent

Commerce amp Trade

Education

FamilyCommunity

Healthcare

Law amp Politics

Science amp Technology

Project FIT rationale design and baseline characteristics of a school- and community-

based intervention to address physical activity and healthy eating among low-income

elementary school children

Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D

Oh HJ Orth J Randall S Mayfield K Holmes D

Source

Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu

Abstract

BACKGROUND

This paper describes Project FIT a collaboration between the public school system local

health systems physicians neighborhood associations businesses faith-based leaders

community agencies and university researchers to develop a multi-faceted approach to

promote physical activity and healthy eating toward the general goal of preventing and

reducing childhood obesity among children in Grand Rapids MI USA

METHODSDESIGN

There are four overall components to Project FIT school community social marketing and

school staff wellness - all that focus on 1) increasing access to safe and affordable physical

activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)

improving the affordability and availability of nutritious food in the neighborhoods surrounding

the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding

nutrition and physical activity among school staff parents and students 4) impacting the

culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging

dialogue among all community partners to leverage existing programs and introduce new

ones

Long-Term Weight Maintenance

National Weight Control Registry (N=10000)

Survey of 3000 members who have been in the

Registry for at least 10 years

Starting weight = 224 lbs Average weight loss=69

lbs

At 5 years participants had maintained an average

weight loss=52 lbs

At 10 years participants had maintained an average

weight loss=51 lbs

Thomas Bond Phelan et al TOS 2011

Long-Term Weight Maintenance

Weight Maintainers report that they usually

Track their food intake

Count calories or fat grams

Follow a low-calorie low fat diet (1800 caloriesday

less than 30 of calories from fat

Eat breakfast regularly

Limit the amount they eat out (about 3 timesweek

eat fast food less than onceweek)

Thomas Bond Phelan et al TOS 2011

Long-Term Weight Maintenance

Weight Maintainers report that they usually

Eat similar food regularly

Donrsquot splurge much on holidays amp special occasions

Walk about one hourday

Watch less than 10 hours of TV a week

Weigh themselves at least once a week

Thomas Bond Phelan et al TOS 2011

LONG-TERM WEIGHT MAINTENANCE

Continued consumption of a low-

calorie diet with moderate fat intake

Limited fast food

High levels of physical activity

Phalen et al Obesity 2006 14 710-716

LONG-TERM WEIGHT MAINTENANCE

Daily weighing improved

maintenance of weight loss

particularly when delivered

face to face

Wing et al NEJM 2006 3551563-1571

Most Promising Strategies For

Preventing Weight Regain

Providing multi-component

programs with ongoing

professional contacts

Physical activityexercise

Portion controlmeal replacements

Extending treatment through

weekly or bi-weekly sessions

Pharmacotherapy

Perri Foreyt amp Anton Preventing Weight Regain After Weight Loss 2008

Most Promising Strategies For

Preventing Weight Regain

Extended treatments have shown

promise in promoting adherence to

the behaviors required for the long-

term maintenance of weight loss

Continuous care approach focused

on reasonable long-term objectives

appears appropriate for most

patients

Perri Foreyt amp Anton Preventing Weight Regain After Weight

Loss 2008

An Example of a successful long-term

intervention

The Look AHEAD Study

Does Weight Loss Reduce

Cardiovascular Disease and Death in

Overweight Individuals with Diabetes

bull Action for HEAlth in Diabetes

bull Objective to examine in overweight

persons with Type 2 Diabetes the long-

term effects of an intensive lifestyle

intervention program compared to

diabetes education and support

bull 16 Centers

bull 5145 overweight volunteers with

diabetes

Look AHEAD

Look AHEAD

Primary End Point Composite

bull Cardiovascular death (including fatal

myocardial infarction and stroke)

bull Non-fatal myocardial infarction

bull Non-fatal stroke

Winston-Salem

Baltimore

Philadelphia

New York

Providence

Boston

Clinical Site Coordinating Center

Clinical Sites

Seattle

Los Angeles

San AntonioHouston

Baton Rouge

Minneapolis

Memphis

Birmingham

Pittsburgh

Denver

Phoenix

Look AHEADParticipants

101100Baseline weight (kg)

589586Age (years)

9496Attended 1 year exam

360359Baseline BMI

1514Insulin Users

3737Minority

6059Women

(N=2574)(N=2630)

DSELifestyle

p lt 0004

Look AHEAD

Study Interventions

bull Diabetes support and education - DSE (control group)

bull Lifestyle intervention ndash ILI (treatment group)

Look AHEAD

Lifestyle Intervention

Goals

bull 7 weight loss for the group (10

for individual)

bull 175 minutes of moderate intensity

activity

Look AHEAD

Lifestyle Intervention

bull Diet

ndash ADA NCEP (lt 30 fat lt 10 sat fat

gt15 protein)

ndash 1200-1500 (if weight lt250lbs)

ndash 1500-1800 (if weight gt250lbs)

ndash During first 4 weeks to 4 months portion

control (liquid meal replacements or

structured meal plan)

Look AHEAD

Lifestyle Intervention

bull Physical Activity

ndash unsupervised

ndash 175 minutes moderate intensityweek

ndash 5 daysweek

ndash walking

Weight Loss at 1-Year

-9

ILI 0

-1

-2

-3

-4

-5

-6

-7

-8

DSE

p lt 00001

W

eig

ht

Chan

ge

86

07

The Look AHEAD Research Group Diabetes Care 2007

Reduction in Initial Weight by Gender

N=872

N=1229N=1197

N=830

-12

-10

-8

-6

-4

-2

0

0 2 4 6 8 10 12

Months

R

ed

uctio

n in

In

itia

l W

eig

ht

Men

Women

Plt0001

The Look AHEAD Research Group Diabetes Care 2007

Fitness Change () at 1-Year

0

5

10

15

20

25

Mean

Fitness C

hange

Unadjusted

Plt0001Adjusted for 1 Year

Weight Change Plt0001

58

209

108

159

DSE ILI ILIDSE

The Look AHEAD Research Group Diabetes Care 2007

1-Year Changes in Markers of

Diabetes Control

Markers of Diabetes

Control ILI DSE P-value

Hemoglobin A1c () BL

Hemoglobin A1c () Y1

Y1 ndash Baseline

725

661

-064

729

715

-014

026

lt0001

lt0001

Fasting glucose (mgdl) BL

Fasting glucose (mgdl) Y1

Y1 ndash Baseline

1519

1304

-215

1536

1464

-72

021

lt0001

lt0001

Diabetes medications BL

Diabetes medications Y1

Y1 ndash Baseline

865

786

-78

865

887

22

093

lt0001

lt0001

1-Year Changes in Markers of

Blood Pressure ControlMarkers of Blood Pressure

Control ILI DSE P-value

Systolic BP (mmHg) BL

Systolic BP (mmHg) Y1

Y1 ndash Baseline

1282

1214

-68

1294

1266

-28

026

lt0001

lt0001

Diastolic BP (mmHg) BL

Diastolic BP (mmHg) Y1

Y1 ndash Baseline

699

670

-30

704

686

-18

011

lt0001

lt0001

Antihypertensive medications BL

Antihypertensive medications Y1

Y1 ndash Baseline

753

752

-01

737

759

22

023

054

002

1-Year Changes in Markers of Lipid

Control

Markers of Lipid Control ILI DSE P-value

LDL-cholesterol (mgdl) BL

LDL-cholesterol (mgdl) Y1

Y1 ndash Baseline

1122

1070

-52

1124

1067

-57

078

074

049

HDL-cholesterol (mgdl) BL

HDL-cholesterol (mgdl) Y1

Y1 ndash Baseline

435

469

34

436

449

14

080

lt0001

lt0001

Triglycerides (mgdl) BL

Triglycerides (mgdl) Y1

Y1 ndash Baseline

1828

1525

-303

1800

1654

-146

038

lt0001

lt0001

Lipid lowering medications BL

Lipid lowering medications Y1

Y1 ndash Baseline

494

530

37

484

578

94

052

lt0001

lt0001

1-Year Changes in Percent of Participants

Meeting ADA Goals

ADA Goal ILI DSE P-value

Hemoglobin A1c lt 7 BL

Hemoglobin A1c lt 7 Y1

Y1 ndash Baseline

463

727

264

454

508

54

050

lt0001

lt0001

Blood pressure lt 13080 mmHg BL

Blood pressure lt 13080 mmHg Y1

Y1 ndash Baseline

535

686

151

499

570

70

001

lt0001

lt0001

LDL-cholesterol lt 100 mgdl BL

LDL-cholesterol lt 100 mgdl Y1

Y1 ndash Baseline

371

438

67

369

449

80

087

045

034

All three goals BL

All three goals Y1

Y1 ndash Baseline

108

236

128

95

160

65

013

lt0001

lt0001

Mean Changes in Weight Fitness amp BP

Averaged Over Four Years

DSE

Mean

ILI

Mean

P-value

Weight Loss

( initial wt)

-088 -615 lt 00001

Fitness

( METS)

196 1274 lt00001

HbA1c -009 -036 lt 00001

SBP (mm Hg) -297 -533 lt 00001

DBP (mm Hg) -248 -292 0012

Look AHEAD Research Group Arch Int Med 2010

Mean Changes in Lipid Profile

Averaged Over Four Years

DSE

Mean

ILI

Mean

P-value

HDL (mgdl) 197 367 lt00001

TG (mgdl) -1975 -2556 00006

LDL (mgdl) -1284 -1127 0009

LDL (mgdl)

(Adjusting for

medication use)

-922 -875 042

Look AHEAD Research Group Arch Int Med 2010

Percent () Completing Outcome

Measures at Years 1-4

Intervention Group

(ILI)

Year 1 971

Year 2 949

Year 3 940

Year 4 941

Comparison Group

(DSE)

Year 1 957

Year 2 935

Year 3 938

Year 4 931

Look AHEAD Summary

ILI had significantly greater improvements than DSE in all CVD risk factors averaged across 4 years (except LDL-C)

There may be long-term beneficial effects from this 4-year period in which ILI subjects have been exposed to lower CVD risk factors

Longer follow-ups will determine whether these lowered CVD risk factors can be maintained amp whether lifestyle intervention has positive effects on CVD morbidity amp mortality

Mary J

Female

White

56 years old at start of Look AHEAD

study

Past Medical History Type 2 diabetes

overweight diverticulosis arthritis

sleep apnea back pain

Mary J

bullLong term strugglesbull Helping youngest daughter with

personal issues and children

bull Rotator cuff problems

bull Degenerative disks in back

bull Rheumatoid arthritis

bull Diabetes

bull Physically demanding job

bull Financial struggles

Pounds

Years

82007 grandkids enter pre-school

Catherine L

Female

White

47 years old at start of Look AHEAD

study

Past Medical History Type 2 diabetes

overweight high blood pressure

hypothyroidism back pain

Catherine L

Long term struggles

bull Motherrsquos declining health and death

bull Multiple serious injuries

bull Sudden death of sister

bull Death of step-father

bull Declining economy

bull Children living at home

Pounds

Years

Realistic Management Goals

5-10 weight loss

Health energy and fitness

Well-being and self-esteem

Mood and appearance

Functional and recreational

activity

Key Elements

Focus on health and energy

Food and physical activity diaries

Gradual increase in physical activity

Gradual reduction in dietary fat

No feelings of food deprivation

Social support groups

Recommended Strategies for Building

Sustainable Healthy Communities

Overview from USA

Promote the availability of affordable healthy

food and beverages

Support healthy food and beverage choices

Encourage breastfeeding

Encourage physical activity or limit sedentary

activity among children amp youth

Create safe communities that support physical

activity

Encourage communities to organize for change

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Increase the availability of healthier food and

beverage choices in public service venues (eg

schools city amp county buildings etc)

--Insufficient evidence in school-based programs

--Associations suggest availability amp increased

consumption

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve availability of affordable healthier

food amp beverage choices in public service

venues

--Reducing the cost of healthier foods

increases their purchase

--Providing coupons redeemable for

healthier foods increases their purchase

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve geographic availability of

supermarkets in underserved areas

-- Greater access to nearby supermarkets is

associated with healthier eating behaviors

-- Increasing the number of supermarkets in

underserved neighborhoods increased

real estate values increased economic

activity amp employment amp resulted in lower

food prices

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Provide incentives to food retailers to locate in

andor offer healthier food choices in

underserved areas

-- Presence of retail venues that provide healthier

foods is associated with better nutrition

-- Greater availability of supermarkets was

associated with lower adolescent BMI scores

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Improve availability of mechanisms for

purchasing foods from farms

--Evidence supporting a direct link between

purchasing food from farms amp improved diet is

limited

--Two studies of initiatives to encourage

participation in farmersrsquo market showed

increased intention to eat more fruits amp

vegetables but no direct evidence

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Provide incentives for the production

distribution and procurement of foods from local

farms

--No evidence has been published to link local

food production amp health outcomes

--There is a current study exploring the potential

nutritional amp health benefits of eating locally

grown foods

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Restrict availability of less healthy foods amp

beverages in public service venues

--No peer-reviewed studies examined the impact

designed to restrict availability of less healthy

foods in public service venues

--21 states have policies that restrict the sale of

competitive foods in schools beyond USDA

regulations however no studies have evaluated

the impact of the policies

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Institute smaller portion size options in public

service venues

--Evidence is lacking to demonstrate effectiveness

of population-based interventions aimed at

reducing portion sizes in public service venues

--Evidence from clinical studies in laboratories

demonstrates decreasing portion sizes

decreases energy intake

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Limit advertisements of less healthy foods amp

beverages

--Little evidence is available regarding the impact

of restricting advertising on purchasing amp

consumption of less healthy foods

--Cross-sectional time-series studies of tobacco-

control efforts suggest an association between

advertising bans amp decreased tobacco

consumption

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Discourage consumption of sugar-sweetened

beverages

--One longitudinal study of a school-based

intervention among Native-American high school

students showed a substantial reduction in

sugar-sweetened beverages over a 3-year

period

--A RCT of a home-based intervention that

eliminated sugar-sweetened beverages showed

reduction in BMI scores

Recommended Community Strategies Strategies to encourage breastfeeding

Increase support for breastfeeding

--Evidence directly linking environmental

interventions that support breastfeeding with

obesity-related outcomes is lacking

--Epidemiologic studies indicate that breastfeeding

helps prevent pediatric obesity

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Require physical education in schools

--14 studies have demonstrated that school-based

PE was effective in increasing levels of physical

activity and improving physical fitness

--Minimum of 150 minwk in elementary schools

225 minwk in middle schools and high schools

throughout the school year as recommended by

NASPE

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Increase opportunities for extracurricular

physical activity

--Participation in after-school programs increased

studentsrsquo level of physical activity amp improved

obesity-related outcomes (improved CV fitness

reduced body fat)

--2 pilot studies providing extracurricular physical

activity showed increased levels of PA amp

decreased sedentary behavior

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Reduce screen time in public service venues

--A school-based RCT indicated that children who

reduced their television videotape amp video

game use had significant decrease in BMI tricep

skin fold thickness amp waist circumference

compared to controls

--Spending less time watching television is

associated with increased physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Improve access to outdoor recreational

facilities

--Review of 108 studies indicated that access to facilities

and programs for recreation near their homes amp time

spent outdoors correlated positively with increased

physical activity among childrenamp adults

--Perceptions that footpaths are safe for walking was

significantly associated with adults being classified as

physically active at a level sufficient for health benefits

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting

bicycling

--Longitudinal intervention studies have

demonstrated that improving bicycling

infrastructure is associated with increased

frequency of bicycling

--Cross-sectional studies indicated a significant

association between bicycling infrastructure amp

frequency of biking

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting walking

--Reviews of cross-sectional studies of

environmental correlates of physical activity amp

walking generally find a positive association

between infrastructure supportive of walking amp

physical activity

--Identifying amp creating safe routes to school

together with educational components

increased the number of students walking to

school

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Locating schools within easy walking

distance of residential areas

--Community-scale urban design amp land use policies amp

practices including locating schools stores workplaces

amp recreation areas close to residential areas are

effective in facilitating an increase in levels of physical

activity

--Majority of efforts to encourage walking to school involve

improving the routes rather than improving the location

of schools

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Improve access to public transportation

--Insufficient evidence exists to determine

effectiveness of transportation policies in

increasing the level of physical activity or

improving fitness

--1 study indicated that 29 of individuals who

walk to and from public transit achieve at least

30 minutes of daily physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Zone for mixed-use development

--Allows residential commercial institutional amp

other public land uses to be located in close

proximity to one another

--Studies using correlation analyses amp regression

models indicated that mixed land use was

associated with increased walking amp cycling

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance personal safety in areas where

persons are or could be physically active

--Cross-sectional studies have demonstrated a

negative relationship between crime rates andor

perceived safety amp physical activity in

neighborhoods

--Few intervention studies have evaluated the

impact of policies amp practices to improve

personal safety on physical activity

Geospatial Mapping Linking Urban

Environments to Health Risk

Measure association between environmental variables amp health risk factors

Assess relationships between variables at different levels of analysis

Used in conjunction with linear analyses

Our Community Environmental Model

of Obesity

Community Factors

Poverty

Crime

Grocery Quality

Restaurants

Parks

Sidewalks

Fast Food Outlets

Recreational

Facilities

Individual Factors

Dietary Intake

Physical Activity

Genetics

Family History

StressCoping

Eating Disorders

Psychological

Problems

Weight

Status

Chosen Neighborhoods

Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped

We then matched census-block groups within the income groups by population density and percentage of minority representation

One matched block group per income level was randomly selected

Prevalence of Obesity in

Block-Groups

0

5

10

15

20

25

30

35

40

45

50

Ag

e-a

dju

sted

Ob

esit

y P

rev

ale

nce

(

)

High-Income Low-Income

Age-standardized to the 1990 US Census

Density of Environmental Factors in the

Community Contributes to a ldquoToxicrdquo

Obesity Environment

0

2

4

6

8

10

12

14

16

18

Fast-food Convenience Store Bars

Den

sity

10

00

perso

ns

High-Income Low-Income

COMMUNITYrsquoS PERCEPTION OF SAFETY

0

5

10

15

20

25

30

35

40

Daytime Nighttime

Perc

en

t (

) F

eeli

ng

So

mew

hat

Safe

or

Un

safe

Low-Income High-Income

Percent Substandard (or worse) Housing

or Ground Conditions

of Residential Properties

0

10

20

30

Structural Grounds

Perc

en

t (

)

Low-Income High-Income

CONCLUSIONS

These data suggest that the higher

frequency of outlets providing

calorically-dense foods and alcohol may

contribute to greater obesity prevalence

in residents of low-income communities

More research is needed to thoroughly

document environmental determinants

of health and obesity

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

From 1994-1998 HUD randomly assigned

4498 women with children living in public

housing in high-poverty urban census

tracts to one of three groups (1) housing

vouchers redeemable only if they moved

to a low-poverty census tract (2)

unrestricted vouchers or (3) control group

(no vouchers)

Ludwig et al NEJM 201136516

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

10-12 year follow-up showed modest but

potentially important reductions in the

prevalence of extreme obesity amp diabetes in the

group moving from a neighborhood with high

poverty on one of low poverty compared to the

control group

No differences between the group receiving

traditional vouchers amp the control group

ldquoNeighborhoods matterrdquo

Ludwig et al NEJM 201136516

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance traffic safety in areas where

persons are or could be physically active

--Community-scale urban design amp land use policies to

promote physical activity including design components

to improve street lighting infrastructure projects to

increase safety of pedestrian street crossing and use of

traffic calming approaches such as speed humps amp

traffic circles are effective in increasing physical activity

--Both community-scale amp street-scale policies amp practices

are effective in increasing physical activity

Recommended Community Strategies Encourage Communities to Organize for Change

Participate in community coalitions or

partnerships to address obesity

--Little evidence is available to determine the

impact of community coalitions on obesity

prevention

--The presence of anti-smoking community

coalitions has been associated with lower rates

of tobacco consumption

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

$103 million awarded to 61 states and

communities including state amp local government

agencies tribes amp territories amp state amp local non-

profit organizations

To build capacity to implement changes for

community prevention efforts to ensure long-

term success

To implement evidence-based and practice-

based programs to improve health amp wellness

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Priority areas are

Tobacco-free living

Active living and healthy eating

Evidence-based quality clinical and other

preventive health services for prevention

and control of high blood pressure and

high cholesterol

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Applicants proposed specific activities in

line with their chosen priority areas in their

applications

Grantee activities will not be finalized until

plans are negotiated with CDC by early

2012

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Capacity-Building Award

The Confederated Tribes of The Chehalis

Reservation is receiving a $498663 planning

award to build capacity to support healthy

lifestyles among their tribal population of 1500

in Washington State

Work will target tobacco-free living active living

and healthy eating and quality clinical and other

healthy serviceswwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Implementation Award

Austin TX Dept of Health and Human Services

is receiving $1026158 to serve Travis County

(Austin) to expand efforts in tobacco-free living

active living and healthy eating quality clinical

and other preventive services social and

emotional wellness and healthy and safe

physical environmentswwwcdcgov1052011

Building sustainable healthy

communities Bottom line

Obesity is an environmental problem

Despite progress in genetic research public health advances only will occur when we take the environment seriously

Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment

Until we do this we will not make substantial progress in addressing the epidemic of obesity

Poston amp Foreyt Atherosclerosis 1999

Whatrsquos the best approach

Integrate all sectors of society into community

change interventions

Incorporate

Science amp Technology

Education

FamilyCommunity

Healthcare

Arts amp Entertainment

Law amp Politics

Commerce amp Trade

Sectors of Society

Arts amp Entertainm

ent

Commerce amp Trade

Education

FamilyCommunity

Healthcare

Law amp Politics

Science amp Technology

Project FIT rationale design and baseline characteristics of a school- and community-

based intervention to address physical activity and healthy eating among low-income

elementary school children

Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D

Oh HJ Orth J Randall S Mayfield K Holmes D

Source

Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu

Abstract

BACKGROUND

This paper describes Project FIT a collaboration between the public school system local

health systems physicians neighborhood associations businesses faith-based leaders

community agencies and university researchers to develop a multi-faceted approach to

promote physical activity and healthy eating toward the general goal of preventing and

reducing childhood obesity among children in Grand Rapids MI USA

METHODSDESIGN

There are four overall components to Project FIT school community social marketing and

school staff wellness - all that focus on 1) increasing access to safe and affordable physical

activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)

improving the affordability and availability of nutritious food in the neighborhoods surrounding

the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding

nutrition and physical activity among school staff parents and students 4) impacting the

culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging

dialogue among all community partners to leverage existing programs and introduce new

ones

Long-Term Weight Maintenance

Weight Maintainers report that they usually

Track their food intake

Count calories or fat grams

Follow a low-calorie low fat diet (1800 caloriesday

less than 30 of calories from fat

Eat breakfast regularly

Limit the amount they eat out (about 3 timesweek

eat fast food less than onceweek)

Thomas Bond Phelan et al TOS 2011

Long-Term Weight Maintenance

Weight Maintainers report that they usually

Eat similar food regularly

Donrsquot splurge much on holidays amp special occasions

Walk about one hourday

Watch less than 10 hours of TV a week

Weigh themselves at least once a week

Thomas Bond Phelan et al TOS 2011

LONG-TERM WEIGHT MAINTENANCE

Continued consumption of a low-

calorie diet with moderate fat intake

Limited fast food

High levels of physical activity

Phalen et al Obesity 2006 14 710-716

LONG-TERM WEIGHT MAINTENANCE

Daily weighing improved

maintenance of weight loss

particularly when delivered

face to face

Wing et al NEJM 2006 3551563-1571

Most Promising Strategies For

Preventing Weight Regain

Providing multi-component

programs with ongoing

professional contacts

Physical activityexercise

Portion controlmeal replacements

Extending treatment through

weekly or bi-weekly sessions

Pharmacotherapy

Perri Foreyt amp Anton Preventing Weight Regain After Weight Loss 2008

Most Promising Strategies For

Preventing Weight Regain

Extended treatments have shown

promise in promoting adherence to

the behaviors required for the long-

term maintenance of weight loss

Continuous care approach focused

on reasonable long-term objectives

appears appropriate for most

patients

Perri Foreyt amp Anton Preventing Weight Regain After Weight

Loss 2008

An Example of a successful long-term

intervention

The Look AHEAD Study

Does Weight Loss Reduce

Cardiovascular Disease and Death in

Overweight Individuals with Diabetes

bull Action for HEAlth in Diabetes

bull Objective to examine in overweight

persons with Type 2 Diabetes the long-

term effects of an intensive lifestyle

intervention program compared to

diabetes education and support

bull 16 Centers

bull 5145 overweight volunteers with

diabetes

Look AHEAD

Look AHEAD

Primary End Point Composite

bull Cardiovascular death (including fatal

myocardial infarction and stroke)

bull Non-fatal myocardial infarction

bull Non-fatal stroke

Winston-Salem

Baltimore

Philadelphia

New York

Providence

Boston

Clinical Site Coordinating Center

Clinical Sites

Seattle

Los Angeles

San AntonioHouston

Baton Rouge

Minneapolis

Memphis

Birmingham

Pittsburgh

Denver

Phoenix

Look AHEADParticipants

101100Baseline weight (kg)

589586Age (years)

9496Attended 1 year exam

360359Baseline BMI

1514Insulin Users

3737Minority

6059Women

(N=2574)(N=2630)

DSELifestyle

p lt 0004

Look AHEAD

Study Interventions

bull Diabetes support and education - DSE (control group)

bull Lifestyle intervention ndash ILI (treatment group)

Look AHEAD

Lifestyle Intervention

Goals

bull 7 weight loss for the group (10

for individual)

bull 175 minutes of moderate intensity

activity

Look AHEAD

Lifestyle Intervention

bull Diet

ndash ADA NCEP (lt 30 fat lt 10 sat fat

gt15 protein)

ndash 1200-1500 (if weight lt250lbs)

ndash 1500-1800 (if weight gt250lbs)

ndash During first 4 weeks to 4 months portion

control (liquid meal replacements or

structured meal plan)

Look AHEAD

Lifestyle Intervention

bull Physical Activity

ndash unsupervised

ndash 175 minutes moderate intensityweek

ndash 5 daysweek

ndash walking

Weight Loss at 1-Year

-9

ILI 0

-1

-2

-3

-4

-5

-6

-7

-8

DSE

p lt 00001

W

eig

ht

Chan

ge

86

07

The Look AHEAD Research Group Diabetes Care 2007

Reduction in Initial Weight by Gender

N=872

N=1229N=1197

N=830

-12

-10

-8

-6

-4

-2

0

0 2 4 6 8 10 12

Months

R

ed

uctio

n in

In

itia

l W

eig

ht

Men

Women

Plt0001

The Look AHEAD Research Group Diabetes Care 2007

Fitness Change () at 1-Year

0

5

10

15

20

25

Mean

Fitness C

hange

Unadjusted

Plt0001Adjusted for 1 Year

Weight Change Plt0001

58

209

108

159

DSE ILI ILIDSE

The Look AHEAD Research Group Diabetes Care 2007

1-Year Changes in Markers of

Diabetes Control

Markers of Diabetes

Control ILI DSE P-value

Hemoglobin A1c () BL

Hemoglobin A1c () Y1

Y1 ndash Baseline

725

661

-064

729

715

-014

026

lt0001

lt0001

Fasting glucose (mgdl) BL

Fasting glucose (mgdl) Y1

Y1 ndash Baseline

1519

1304

-215

1536

1464

-72

021

lt0001

lt0001

Diabetes medications BL

Diabetes medications Y1

Y1 ndash Baseline

865

786

-78

865

887

22

093

lt0001

lt0001

1-Year Changes in Markers of

Blood Pressure ControlMarkers of Blood Pressure

Control ILI DSE P-value

Systolic BP (mmHg) BL

Systolic BP (mmHg) Y1

Y1 ndash Baseline

1282

1214

-68

1294

1266

-28

026

lt0001

lt0001

Diastolic BP (mmHg) BL

Diastolic BP (mmHg) Y1

Y1 ndash Baseline

699

670

-30

704

686

-18

011

lt0001

lt0001

Antihypertensive medications BL

Antihypertensive medications Y1

Y1 ndash Baseline

753

752

-01

737

759

22

023

054

002

1-Year Changes in Markers of Lipid

Control

Markers of Lipid Control ILI DSE P-value

LDL-cholesterol (mgdl) BL

LDL-cholesterol (mgdl) Y1

Y1 ndash Baseline

1122

1070

-52

1124

1067

-57

078

074

049

HDL-cholesterol (mgdl) BL

HDL-cholesterol (mgdl) Y1

Y1 ndash Baseline

435

469

34

436

449

14

080

lt0001

lt0001

Triglycerides (mgdl) BL

Triglycerides (mgdl) Y1

Y1 ndash Baseline

1828

1525

-303

1800

1654

-146

038

lt0001

lt0001

Lipid lowering medications BL

Lipid lowering medications Y1

Y1 ndash Baseline

494

530

37

484

578

94

052

lt0001

lt0001

1-Year Changes in Percent of Participants

Meeting ADA Goals

ADA Goal ILI DSE P-value

Hemoglobin A1c lt 7 BL

Hemoglobin A1c lt 7 Y1

Y1 ndash Baseline

463

727

264

454

508

54

050

lt0001

lt0001

Blood pressure lt 13080 mmHg BL

Blood pressure lt 13080 mmHg Y1

Y1 ndash Baseline

535

686

151

499

570

70

001

lt0001

lt0001

LDL-cholesterol lt 100 mgdl BL

LDL-cholesterol lt 100 mgdl Y1

Y1 ndash Baseline

371

438

67

369

449

80

087

045

034

All three goals BL

All three goals Y1

Y1 ndash Baseline

108

236

128

95

160

65

013

lt0001

lt0001

Mean Changes in Weight Fitness amp BP

Averaged Over Four Years

DSE

Mean

ILI

Mean

P-value

Weight Loss

( initial wt)

-088 -615 lt 00001

Fitness

( METS)

196 1274 lt00001

HbA1c -009 -036 lt 00001

SBP (mm Hg) -297 -533 lt 00001

DBP (mm Hg) -248 -292 0012

Look AHEAD Research Group Arch Int Med 2010

Mean Changes in Lipid Profile

Averaged Over Four Years

DSE

Mean

ILI

Mean

P-value

HDL (mgdl) 197 367 lt00001

TG (mgdl) -1975 -2556 00006

LDL (mgdl) -1284 -1127 0009

LDL (mgdl)

(Adjusting for

medication use)

-922 -875 042

Look AHEAD Research Group Arch Int Med 2010

Percent () Completing Outcome

Measures at Years 1-4

Intervention Group

(ILI)

Year 1 971

Year 2 949

Year 3 940

Year 4 941

Comparison Group

(DSE)

Year 1 957

Year 2 935

Year 3 938

Year 4 931

Look AHEAD Summary

ILI had significantly greater improvements than DSE in all CVD risk factors averaged across 4 years (except LDL-C)

There may be long-term beneficial effects from this 4-year period in which ILI subjects have been exposed to lower CVD risk factors

Longer follow-ups will determine whether these lowered CVD risk factors can be maintained amp whether lifestyle intervention has positive effects on CVD morbidity amp mortality

Mary J

Female

White

56 years old at start of Look AHEAD

study

Past Medical History Type 2 diabetes

overweight diverticulosis arthritis

sleep apnea back pain

Mary J

bullLong term strugglesbull Helping youngest daughter with

personal issues and children

bull Rotator cuff problems

bull Degenerative disks in back

bull Rheumatoid arthritis

bull Diabetes

bull Physically demanding job

bull Financial struggles

Pounds

Years

82007 grandkids enter pre-school

Catherine L

Female

White

47 years old at start of Look AHEAD

study

Past Medical History Type 2 diabetes

overweight high blood pressure

hypothyroidism back pain

Catherine L

Long term struggles

bull Motherrsquos declining health and death

bull Multiple serious injuries

bull Sudden death of sister

bull Death of step-father

bull Declining economy

bull Children living at home

Pounds

Years

Realistic Management Goals

5-10 weight loss

Health energy and fitness

Well-being and self-esteem

Mood and appearance

Functional and recreational

activity

Key Elements

Focus on health and energy

Food and physical activity diaries

Gradual increase in physical activity

Gradual reduction in dietary fat

No feelings of food deprivation

Social support groups

Recommended Strategies for Building

Sustainable Healthy Communities

Overview from USA

Promote the availability of affordable healthy

food and beverages

Support healthy food and beverage choices

Encourage breastfeeding

Encourage physical activity or limit sedentary

activity among children amp youth

Create safe communities that support physical

activity

Encourage communities to organize for change

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Increase the availability of healthier food and

beverage choices in public service venues (eg

schools city amp county buildings etc)

--Insufficient evidence in school-based programs

--Associations suggest availability amp increased

consumption

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve availability of affordable healthier

food amp beverage choices in public service

venues

--Reducing the cost of healthier foods

increases their purchase

--Providing coupons redeemable for

healthier foods increases their purchase

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve geographic availability of

supermarkets in underserved areas

-- Greater access to nearby supermarkets is

associated with healthier eating behaviors

-- Increasing the number of supermarkets in

underserved neighborhoods increased

real estate values increased economic

activity amp employment amp resulted in lower

food prices

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Provide incentives to food retailers to locate in

andor offer healthier food choices in

underserved areas

-- Presence of retail venues that provide healthier

foods is associated with better nutrition

-- Greater availability of supermarkets was

associated with lower adolescent BMI scores

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Improve availability of mechanisms for

purchasing foods from farms

--Evidence supporting a direct link between

purchasing food from farms amp improved diet is

limited

--Two studies of initiatives to encourage

participation in farmersrsquo market showed

increased intention to eat more fruits amp

vegetables but no direct evidence

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Provide incentives for the production

distribution and procurement of foods from local

farms

--No evidence has been published to link local

food production amp health outcomes

--There is a current study exploring the potential

nutritional amp health benefits of eating locally

grown foods

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Restrict availability of less healthy foods amp

beverages in public service venues

--No peer-reviewed studies examined the impact

designed to restrict availability of less healthy

foods in public service venues

--21 states have policies that restrict the sale of

competitive foods in schools beyond USDA

regulations however no studies have evaluated

the impact of the policies

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Institute smaller portion size options in public

service venues

--Evidence is lacking to demonstrate effectiveness

of population-based interventions aimed at

reducing portion sizes in public service venues

--Evidence from clinical studies in laboratories

demonstrates decreasing portion sizes

decreases energy intake

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Limit advertisements of less healthy foods amp

beverages

--Little evidence is available regarding the impact

of restricting advertising on purchasing amp

consumption of less healthy foods

--Cross-sectional time-series studies of tobacco-

control efforts suggest an association between

advertising bans amp decreased tobacco

consumption

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Discourage consumption of sugar-sweetened

beverages

--One longitudinal study of a school-based

intervention among Native-American high school

students showed a substantial reduction in

sugar-sweetened beverages over a 3-year

period

--A RCT of a home-based intervention that

eliminated sugar-sweetened beverages showed

reduction in BMI scores

Recommended Community Strategies Strategies to encourage breastfeeding

Increase support for breastfeeding

--Evidence directly linking environmental

interventions that support breastfeeding with

obesity-related outcomes is lacking

--Epidemiologic studies indicate that breastfeeding

helps prevent pediatric obesity

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Require physical education in schools

--14 studies have demonstrated that school-based

PE was effective in increasing levels of physical

activity and improving physical fitness

--Minimum of 150 minwk in elementary schools

225 minwk in middle schools and high schools

throughout the school year as recommended by

NASPE

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Increase opportunities for extracurricular

physical activity

--Participation in after-school programs increased

studentsrsquo level of physical activity amp improved

obesity-related outcomes (improved CV fitness

reduced body fat)

--2 pilot studies providing extracurricular physical

activity showed increased levels of PA amp

decreased sedentary behavior

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Reduce screen time in public service venues

--A school-based RCT indicated that children who

reduced their television videotape amp video

game use had significant decrease in BMI tricep

skin fold thickness amp waist circumference

compared to controls

--Spending less time watching television is

associated with increased physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Improve access to outdoor recreational

facilities

--Review of 108 studies indicated that access to facilities

and programs for recreation near their homes amp time

spent outdoors correlated positively with increased

physical activity among childrenamp adults

--Perceptions that footpaths are safe for walking was

significantly associated with adults being classified as

physically active at a level sufficient for health benefits

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting

bicycling

--Longitudinal intervention studies have

demonstrated that improving bicycling

infrastructure is associated with increased

frequency of bicycling

--Cross-sectional studies indicated a significant

association between bicycling infrastructure amp

frequency of biking

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting walking

--Reviews of cross-sectional studies of

environmental correlates of physical activity amp

walking generally find a positive association

between infrastructure supportive of walking amp

physical activity

--Identifying amp creating safe routes to school

together with educational components

increased the number of students walking to

school

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Locating schools within easy walking

distance of residential areas

--Community-scale urban design amp land use policies amp

practices including locating schools stores workplaces

amp recreation areas close to residential areas are

effective in facilitating an increase in levels of physical

activity

--Majority of efforts to encourage walking to school involve

improving the routes rather than improving the location

of schools

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Improve access to public transportation

--Insufficient evidence exists to determine

effectiveness of transportation policies in

increasing the level of physical activity or

improving fitness

--1 study indicated that 29 of individuals who

walk to and from public transit achieve at least

30 minutes of daily physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Zone for mixed-use development

--Allows residential commercial institutional amp

other public land uses to be located in close

proximity to one another

--Studies using correlation analyses amp regression

models indicated that mixed land use was

associated with increased walking amp cycling

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance personal safety in areas where

persons are or could be physically active

--Cross-sectional studies have demonstrated a

negative relationship between crime rates andor

perceived safety amp physical activity in

neighborhoods

--Few intervention studies have evaluated the

impact of policies amp practices to improve

personal safety on physical activity

Geospatial Mapping Linking Urban

Environments to Health Risk

Measure association between environmental variables amp health risk factors

Assess relationships between variables at different levels of analysis

Used in conjunction with linear analyses

Our Community Environmental Model

of Obesity

Community Factors

Poverty

Crime

Grocery Quality

Restaurants

Parks

Sidewalks

Fast Food Outlets

Recreational

Facilities

Individual Factors

Dietary Intake

Physical Activity

Genetics

Family History

StressCoping

Eating Disorders

Psychological

Problems

Weight

Status

Chosen Neighborhoods

Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped

We then matched census-block groups within the income groups by population density and percentage of minority representation

One matched block group per income level was randomly selected

Prevalence of Obesity in

Block-Groups

0

5

10

15

20

25

30

35

40

45

50

Ag

e-a

dju

sted

Ob

esit

y P

rev

ale

nce

(

)

High-Income Low-Income

Age-standardized to the 1990 US Census

Density of Environmental Factors in the

Community Contributes to a ldquoToxicrdquo

Obesity Environment

0

2

4

6

8

10

12

14

16

18

Fast-food Convenience Store Bars

Den

sity

10

00

perso

ns

High-Income Low-Income

COMMUNITYrsquoS PERCEPTION OF SAFETY

0

5

10

15

20

25

30

35

40

Daytime Nighttime

Perc

en

t (

) F

eeli

ng

So

mew

hat

Safe

or

Un

safe

Low-Income High-Income

Percent Substandard (or worse) Housing

or Ground Conditions

of Residential Properties

0

10

20

30

Structural Grounds

Perc

en

t (

)

Low-Income High-Income

CONCLUSIONS

These data suggest that the higher

frequency of outlets providing

calorically-dense foods and alcohol may

contribute to greater obesity prevalence

in residents of low-income communities

More research is needed to thoroughly

document environmental determinants

of health and obesity

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

From 1994-1998 HUD randomly assigned

4498 women with children living in public

housing in high-poverty urban census

tracts to one of three groups (1) housing

vouchers redeemable only if they moved

to a low-poverty census tract (2)

unrestricted vouchers or (3) control group

(no vouchers)

Ludwig et al NEJM 201136516

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

10-12 year follow-up showed modest but

potentially important reductions in the

prevalence of extreme obesity amp diabetes in the

group moving from a neighborhood with high

poverty on one of low poverty compared to the

control group

No differences between the group receiving

traditional vouchers amp the control group

ldquoNeighborhoods matterrdquo

Ludwig et al NEJM 201136516

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance traffic safety in areas where

persons are or could be physically active

--Community-scale urban design amp land use policies to

promote physical activity including design components

to improve street lighting infrastructure projects to

increase safety of pedestrian street crossing and use of

traffic calming approaches such as speed humps amp

traffic circles are effective in increasing physical activity

--Both community-scale amp street-scale policies amp practices

are effective in increasing physical activity

Recommended Community Strategies Encourage Communities to Organize for Change

Participate in community coalitions or

partnerships to address obesity

--Little evidence is available to determine the

impact of community coalitions on obesity

prevention

--The presence of anti-smoking community

coalitions has been associated with lower rates

of tobacco consumption

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

$103 million awarded to 61 states and

communities including state amp local government

agencies tribes amp territories amp state amp local non-

profit organizations

To build capacity to implement changes for

community prevention efforts to ensure long-

term success

To implement evidence-based and practice-

based programs to improve health amp wellness

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Priority areas are

Tobacco-free living

Active living and healthy eating

Evidence-based quality clinical and other

preventive health services for prevention

and control of high blood pressure and

high cholesterol

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Applicants proposed specific activities in

line with their chosen priority areas in their

applications

Grantee activities will not be finalized until

plans are negotiated with CDC by early

2012

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Capacity-Building Award

The Confederated Tribes of The Chehalis

Reservation is receiving a $498663 planning

award to build capacity to support healthy

lifestyles among their tribal population of 1500

in Washington State

Work will target tobacco-free living active living

and healthy eating and quality clinical and other

healthy serviceswwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Implementation Award

Austin TX Dept of Health and Human Services

is receiving $1026158 to serve Travis County

(Austin) to expand efforts in tobacco-free living

active living and healthy eating quality clinical

and other preventive services social and

emotional wellness and healthy and safe

physical environmentswwwcdcgov1052011

Building sustainable healthy

communities Bottom line

Obesity is an environmental problem

Despite progress in genetic research public health advances only will occur when we take the environment seriously

Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment

Until we do this we will not make substantial progress in addressing the epidemic of obesity

Poston amp Foreyt Atherosclerosis 1999

Whatrsquos the best approach

Integrate all sectors of society into community

change interventions

Incorporate

Science amp Technology

Education

FamilyCommunity

Healthcare

Arts amp Entertainment

Law amp Politics

Commerce amp Trade

Sectors of Society

Arts amp Entertainm

ent

Commerce amp Trade

Education

FamilyCommunity

Healthcare

Law amp Politics

Science amp Technology

Project FIT rationale design and baseline characteristics of a school- and community-

based intervention to address physical activity and healthy eating among low-income

elementary school children

Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D

Oh HJ Orth J Randall S Mayfield K Holmes D

Source

Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu

Abstract

BACKGROUND

This paper describes Project FIT a collaboration between the public school system local

health systems physicians neighborhood associations businesses faith-based leaders

community agencies and university researchers to develop a multi-faceted approach to

promote physical activity and healthy eating toward the general goal of preventing and

reducing childhood obesity among children in Grand Rapids MI USA

METHODSDESIGN

There are four overall components to Project FIT school community social marketing and

school staff wellness - all that focus on 1) increasing access to safe and affordable physical

activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)

improving the affordability and availability of nutritious food in the neighborhoods surrounding

the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding

nutrition and physical activity among school staff parents and students 4) impacting the

culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging

dialogue among all community partners to leverage existing programs and introduce new

ones

Long-Term Weight Maintenance

Weight Maintainers report that they usually

Eat similar food regularly

Donrsquot splurge much on holidays amp special occasions

Walk about one hourday

Watch less than 10 hours of TV a week

Weigh themselves at least once a week

Thomas Bond Phelan et al TOS 2011

LONG-TERM WEIGHT MAINTENANCE

Continued consumption of a low-

calorie diet with moderate fat intake

Limited fast food

High levels of physical activity

Phalen et al Obesity 2006 14 710-716

LONG-TERM WEIGHT MAINTENANCE

Daily weighing improved

maintenance of weight loss

particularly when delivered

face to face

Wing et al NEJM 2006 3551563-1571

Most Promising Strategies For

Preventing Weight Regain

Providing multi-component

programs with ongoing

professional contacts

Physical activityexercise

Portion controlmeal replacements

Extending treatment through

weekly or bi-weekly sessions

Pharmacotherapy

Perri Foreyt amp Anton Preventing Weight Regain After Weight Loss 2008

Most Promising Strategies For

Preventing Weight Regain

Extended treatments have shown

promise in promoting adherence to

the behaviors required for the long-

term maintenance of weight loss

Continuous care approach focused

on reasonable long-term objectives

appears appropriate for most

patients

Perri Foreyt amp Anton Preventing Weight Regain After Weight

Loss 2008

An Example of a successful long-term

intervention

The Look AHEAD Study

Does Weight Loss Reduce

Cardiovascular Disease and Death in

Overweight Individuals with Diabetes

bull Action for HEAlth in Diabetes

bull Objective to examine in overweight

persons with Type 2 Diabetes the long-

term effects of an intensive lifestyle

intervention program compared to

diabetes education and support

bull 16 Centers

bull 5145 overweight volunteers with

diabetes

Look AHEAD

Look AHEAD

Primary End Point Composite

bull Cardiovascular death (including fatal

myocardial infarction and stroke)

bull Non-fatal myocardial infarction

bull Non-fatal stroke

Winston-Salem

Baltimore

Philadelphia

New York

Providence

Boston

Clinical Site Coordinating Center

Clinical Sites

Seattle

Los Angeles

San AntonioHouston

Baton Rouge

Minneapolis

Memphis

Birmingham

Pittsburgh

Denver

Phoenix

Look AHEADParticipants

101100Baseline weight (kg)

589586Age (years)

9496Attended 1 year exam

360359Baseline BMI

1514Insulin Users

3737Minority

6059Women

(N=2574)(N=2630)

DSELifestyle

p lt 0004

Look AHEAD

Study Interventions

bull Diabetes support and education - DSE (control group)

bull Lifestyle intervention ndash ILI (treatment group)

Look AHEAD

Lifestyle Intervention

Goals

bull 7 weight loss for the group (10

for individual)

bull 175 minutes of moderate intensity

activity

Look AHEAD

Lifestyle Intervention

bull Diet

ndash ADA NCEP (lt 30 fat lt 10 sat fat

gt15 protein)

ndash 1200-1500 (if weight lt250lbs)

ndash 1500-1800 (if weight gt250lbs)

ndash During first 4 weeks to 4 months portion

control (liquid meal replacements or

structured meal plan)

Look AHEAD

Lifestyle Intervention

bull Physical Activity

ndash unsupervised

ndash 175 minutes moderate intensityweek

ndash 5 daysweek

ndash walking

Weight Loss at 1-Year

-9

ILI 0

-1

-2

-3

-4

-5

-6

-7

-8

DSE

p lt 00001

W

eig

ht

Chan

ge

86

07

The Look AHEAD Research Group Diabetes Care 2007

Reduction in Initial Weight by Gender

N=872

N=1229N=1197

N=830

-12

-10

-8

-6

-4

-2

0

0 2 4 6 8 10 12

Months

R

ed

uctio

n in

In

itia

l W

eig

ht

Men

Women

Plt0001

The Look AHEAD Research Group Diabetes Care 2007

Fitness Change () at 1-Year

0

5

10

15

20

25

Mean

Fitness C

hange

Unadjusted

Plt0001Adjusted for 1 Year

Weight Change Plt0001

58

209

108

159

DSE ILI ILIDSE

The Look AHEAD Research Group Diabetes Care 2007

1-Year Changes in Markers of

Diabetes Control

Markers of Diabetes

Control ILI DSE P-value

Hemoglobin A1c () BL

Hemoglobin A1c () Y1

Y1 ndash Baseline

725

661

-064

729

715

-014

026

lt0001

lt0001

Fasting glucose (mgdl) BL

Fasting glucose (mgdl) Y1

Y1 ndash Baseline

1519

1304

-215

1536

1464

-72

021

lt0001

lt0001

Diabetes medications BL

Diabetes medications Y1

Y1 ndash Baseline

865

786

-78

865

887

22

093

lt0001

lt0001

1-Year Changes in Markers of

Blood Pressure ControlMarkers of Blood Pressure

Control ILI DSE P-value

Systolic BP (mmHg) BL

Systolic BP (mmHg) Y1

Y1 ndash Baseline

1282

1214

-68

1294

1266

-28

026

lt0001

lt0001

Diastolic BP (mmHg) BL

Diastolic BP (mmHg) Y1

Y1 ndash Baseline

699

670

-30

704

686

-18

011

lt0001

lt0001

Antihypertensive medications BL

Antihypertensive medications Y1

Y1 ndash Baseline

753

752

-01

737

759

22

023

054

002

1-Year Changes in Markers of Lipid

Control

Markers of Lipid Control ILI DSE P-value

LDL-cholesterol (mgdl) BL

LDL-cholesterol (mgdl) Y1

Y1 ndash Baseline

1122

1070

-52

1124

1067

-57

078

074

049

HDL-cholesterol (mgdl) BL

HDL-cholesterol (mgdl) Y1

Y1 ndash Baseline

435

469

34

436

449

14

080

lt0001

lt0001

Triglycerides (mgdl) BL

Triglycerides (mgdl) Y1

Y1 ndash Baseline

1828

1525

-303

1800

1654

-146

038

lt0001

lt0001

Lipid lowering medications BL

Lipid lowering medications Y1

Y1 ndash Baseline

494

530

37

484

578

94

052

lt0001

lt0001

1-Year Changes in Percent of Participants

Meeting ADA Goals

ADA Goal ILI DSE P-value

Hemoglobin A1c lt 7 BL

Hemoglobin A1c lt 7 Y1

Y1 ndash Baseline

463

727

264

454

508

54

050

lt0001

lt0001

Blood pressure lt 13080 mmHg BL

Blood pressure lt 13080 mmHg Y1

Y1 ndash Baseline

535

686

151

499

570

70

001

lt0001

lt0001

LDL-cholesterol lt 100 mgdl BL

LDL-cholesterol lt 100 mgdl Y1

Y1 ndash Baseline

371

438

67

369

449

80

087

045

034

All three goals BL

All three goals Y1

Y1 ndash Baseline

108

236

128

95

160

65

013

lt0001

lt0001

Mean Changes in Weight Fitness amp BP

Averaged Over Four Years

DSE

Mean

ILI

Mean

P-value

Weight Loss

( initial wt)

-088 -615 lt 00001

Fitness

( METS)

196 1274 lt00001

HbA1c -009 -036 lt 00001

SBP (mm Hg) -297 -533 lt 00001

DBP (mm Hg) -248 -292 0012

Look AHEAD Research Group Arch Int Med 2010

Mean Changes in Lipid Profile

Averaged Over Four Years

DSE

Mean

ILI

Mean

P-value

HDL (mgdl) 197 367 lt00001

TG (mgdl) -1975 -2556 00006

LDL (mgdl) -1284 -1127 0009

LDL (mgdl)

(Adjusting for

medication use)

-922 -875 042

Look AHEAD Research Group Arch Int Med 2010

Percent () Completing Outcome

Measures at Years 1-4

Intervention Group

(ILI)

Year 1 971

Year 2 949

Year 3 940

Year 4 941

Comparison Group

(DSE)

Year 1 957

Year 2 935

Year 3 938

Year 4 931

Look AHEAD Summary

ILI had significantly greater improvements than DSE in all CVD risk factors averaged across 4 years (except LDL-C)

There may be long-term beneficial effects from this 4-year period in which ILI subjects have been exposed to lower CVD risk factors

Longer follow-ups will determine whether these lowered CVD risk factors can be maintained amp whether lifestyle intervention has positive effects on CVD morbidity amp mortality

Mary J

Female

White

56 years old at start of Look AHEAD

study

Past Medical History Type 2 diabetes

overweight diverticulosis arthritis

sleep apnea back pain

Mary J

bullLong term strugglesbull Helping youngest daughter with

personal issues and children

bull Rotator cuff problems

bull Degenerative disks in back

bull Rheumatoid arthritis

bull Diabetes

bull Physically demanding job

bull Financial struggles

Pounds

Years

82007 grandkids enter pre-school

Catherine L

Female

White

47 years old at start of Look AHEAD

study

Past Medical History Type 2 diabetes

overweight high blood pressure

hypothyroidism back pain

Catherine L

Long term struggles

bull Motherrsquos declining health and death

bull Multiple serious injuries

bull Sudden death of sister

bull Death of step-father

bull Declining economy

bull Children living at home

Pounds

Years

Realistic Management Goals

5-10 weight loss

Health energy and fitness

Well-being and self-esteem

Mood and appearance

Functional and recreational

activity

Key Elements

Focus on health and energy

Food and physical activity diaries

Gradual increase in physical activity

Gradual reduction in dietary fat

No feelings of food deprivation

Social support groups

Recommended Strategies for Building

Sustainable Healthy Communities

Overview from USA

Promote the availability of affordable healthy

food and beverages

Support healthy food and beverage choices

Encourage breastfeeding

Encourage physical activity or limit sedentary

activity among children amp youth

Create safe communities that support physical

activity

Encourage communities to organize for change

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Increase the availability of healthier food and

beverage choices in public service venues (eg

schools city amp county buildings etc)

--Insufficient evidence in school-based programs

--Associations suggest availability amp increased

consumption

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve availability of affordable healthier

food amp beverage choices in public service

venues

--Reducing the cost of healthier foods

increases their purchase

--Providing coupons redeemable for

healthier foods increases their purchase

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve geographic availability of

supermarkets in underserved areas

-- Greater access to nearby supermarkets is

associated with healthier eating behaviors

-- Increasing the number of supermarkets in

underserved neighborhoods increased

real estate values increased economic

activity amp employment amp resulted in lower

food prices

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Provide incentives to food retailers to locate in

andor offer healthier food choices in

underserved areas

-- Presence of retail venues that provide healthier

foods is associated with better nutrition

-- Greater availability of supermarkets was

associated with lower adolescent BMI scores

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Improve availability of mechanisms for

purchasing foods from farms

--Evidence supporting a direct link between

purchasing food from farms amp improved diet is

limited

--Two studies of initiatives to encourage

participation in farmersrsquo market showed

increased intention to eat more fruits amp

vegetables but no direct evidence

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Provide incentives for the production

distribution and procurement of foods from local

farms

--No evidence has been published to link local

food production amp health outcomes

--There is a current study exploring the potential

nutritional amp health benefits of eating locally

grown foods

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Restrict availability of less healthy foods amp

beverages in public service venues

--No peer-reviewed studies examined the impact

designed to restrict availability of less healthy

foods in public service venues

--21 states have policies that restrict the sale of

competitive foods in schools beyond USDA

regulations however no studies have evaluated

the impact of the policies

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Institute smaller portion size options in public

service venues

--Evidence is lacking to demonstrate effectiveness

of population-based interventions aimed at

reducing portion sizes in public service venues

--Evidence from clinical studies in laboratories

demonstrates decreasing portion sizes

decreases energy intake

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Limit advertisements of less healthy foods amp

beverages

--Little evidence is available regarding the impact

of restricting advertising on purchasing amp

consumption of less healthy foods

--Cross-sectional time-series studies of tobacco-

control efforts suggest an association between

advertising bans amp decreased tobacco

consumption

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Discourage consumption of sugar-sweetened

beverages

--One longitudinal study of a school-based

intervention among Native-American high school

students showed a substantial reduction in

sugar-sweetened beverages over a 3-year

period

--A RCT of a home-based intervention that

eliminated sugar-sweetened beverages showed

reduction in BMI scores

Recommended Community Strategies Strategies to encourage breastfeeding

Increase support for breastfeeding

--Evidence directly linking environmental

interventions that support breastfeeding with

obesity-related outcomes is lacking

--Epidemiologic studies indicate that breastfeeding

helps prevent pediatric obesity

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Require physical education in schools

--14 studies have demonstrated that school-based

PE was effective in increasing levels of physical

activity and improving physical fitness

--Minimum of 150 minwk in elementary schools

225 minwk in middle schools and high schools

throughout the school year as recommended by

NASPE

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Increase opportunities for extracurricular

physical activity

--Participation in after-school programs increased

studentsrsquo level of physical activity amp improved

obesity-related outcomes (improved CV fitness

reduced body fat)

--2 pilot studies providing extracurricular physical

activity showed increased levels of PA amp

decreased sedentary behavior

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Reduce screen time in public service venues

--A school-based RCT indicated that children who

reduced their television videotape amp video

game use had significant decrease in BMI tricep

skin fold thickness amp waist circumference

compared to controls

--Spending less time watching television is

associated with increased physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Improve access to outdoor recreational

facilities

--Review of 108 studies indicated that access to facilities

and programs for recreation near their homes amp time

spent outdoors correlated positively with increased

physical activity among childrenamp adults

--Perceptions that footpaths are safe for walking was

significantly associated with adults being classified as

physically active at a level sufficient for health benefits

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting

bicycling

--Longitudinal intervention studies have

demonstrated that improving bicycling

infrastructure is associated with increased

frequency of bicycling

--Cross-sectional studies indicated a significant

association between bicycling infrastructure amp

frequency of biking

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting walking

--Reviews of cross-sectional studies of

environmental correlates of physical activity amp

walking generally find a positive association

between infrastructure supportive of walking amp

physical activity

--Identifying amp creating safe routes to school

together with educational components

increased the number of students walking to

school

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Locating schools within easy walking

distance of residential areas

--Community-scale urban design amp land use policies amp

practices including locating schools stores workplaces

amp recreation areas close to residential areas are

effective in facilitating an increase in levels of physical

activity

--Majority of efforts to encourage walking to school involve

improving the routes rather than improving the location

of schools

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Improve access to public transportation

--Insufficient evidence exists to determine

effectiveness of transportation policies in

increasing the level of physical activity or

improving fitness

--1 study indicated that 29 of individuals who

walk to and from public transit achieve at least

30 minutes of daily physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Zone for mixed-use development

--Allows residential commercial institutional amp

other public land uses to be located in close

proximity to one another

--Studies using correlation analyses amp regression

models indicated that mixed land use was

associated with increased walking amp cycling

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance personal safety in areas where

persons are or could be physically active

--Cross-sectional studies have demonstrated a

negative relationship between crime rates andor

perceived safety amp physical activity in

neighborhoods

--Few intervention studies have evaluated the

impact of policies amp practices to improve

personal safety on physical activity

Geospatial Mapping Linking Urban

Environments to Health Risk

Measure association between environmental variables amp health risk factors

Assess relationships between variables at different levels of analysis

Used in conjunction with linear analyses

Our Community Environmental Model

of Obesity

Community Factors

Poverty

Crime

Grocery Quality

Restaurants

Parks

Sidewalks

Fast Food Outlets

Recreational

Facilities

Individual Factors

Dietary Intake

Physical Activity

Genetics

Family History

StressCoping

Eating Disorders

Psychological

Problems

Weight

Status

Chosen Neighborhoods

Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped

We then matched census-block groups within the income groups by population density and percentage of minority representation

One matched block group per income level was randomly selected

Prevalence of Obesity in

Block-Groups

0

5

10

15

20

25

30

35

40

45

50

Ag

e-a

dju

sted

Ob

esit

y P

rev

ale

nce

(

)

High-Income Low-Income

Age-standardized to the 1990 US Census

Density of Environmental Factors in the

Community Contributes to a ldquoToxicrdquo

Obesity Environment

0

2

4

6

8

10

12

14

16

18

Fast-food Convenience Store Bars

Den

sity

10

00

perso

ns

High-Income Low-Income

COMMUNITYrsquoS PERCEPTION OF SAFETY

0

5

10

15

20

25

30

35

40

Daytime Nighttime

Perc

en

t (

) F

eeli

ng

So

mew

hat

Safe

or

Un

safe

Low-Income High-Income

Percent Substandard (or worse) Housing

or Ground Conditions

of Residential Properties

0

10

20

30

Structural Grounds

Perc

en

t (

)

Low-Income High-Income

CONCLUSIONS

These data suggest that the higher

frequency of outlets providing

calorically-dense foods and alcohol may

contribute to greater obesity prevalence

in residents of low-income communities

More research is needed to thoroughly

document environmental determinants

of health and obesity

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

From 1994-1998 HUD randomly assigned

4498 women with children living in public

housing in high-poverty urban census

tracts to one of three groups (1) housing

vouchers redeemable only if they moved

to a low-poverty census tract (2)

unrestricted vouchers or (3) control group

(no vouchers)

Ludwig et al NEJM 201136516

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

10-12 year follow-up showed modest but

potentially important reductions in the

prevalence of extreme obesity amp diabetes in the

group moving from a neighborhood with high

poverty on one of low poverty compared to the

control group

No differences between the group receiving

traditional vouchers amp the control group

ldquoNeighborhoods matterrdquo

Ludwig et al NEJM 201136516

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance traffic safety in areas where

persons are or could be physically active

--Community-scale urban design amp land use policies to

promote physical activity including design components

to improve street lighting infrastructure projects to

increase safety of pedestrian street crossing and use of

traffic calming approaches such as speed humps amp

traffic circles are effective in increasing physical activity

--Both community-scale amp street-scale policies amp practices

are effective in increasing physical activity

Recommended Community Strategies Encourage Communities to Organize for Change

Participate in community coalitions or

partnerships to address obesity

--Little evidence is available to determine the

impact of community coalitions on obesity

prevention

--The presence of anti-smoking community

coalitions has been associated with lower rates

of tobacco consumption

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

$103 million awarded to 61 states and

communities including state amp local government

agencies tribes amp territories amp state amp local non-

profit organizations

To build capacity to implement changes for

community prevention efforts to ensure long-

term success

To implement evidence-based and practice-

based programs to improve health amp wellness

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Priority areas are

Tobacco-free living

Active living and healthy eating

Evidence-based quality clinical and other

preventive health services for prevention

and control of high blood pressure and

high cholesterol

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Applicants proposed specific activities in

line with their chosen priority areas in their

applications

Grantee activities will not be finalized until

plans are negotiated with CDC by early

2012

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Capacity-Building Award

The Confederated Tribes of The Chehalis

Reservation is receiving a $498663 planning

award to build capacity to support healthy

lifestyles among their tribal population of 1500

in Washington State

Work will target tobacco-free living active living

and healthy eating and quality clinical and other

healthy serviceswwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Implementation Award

Austin TX Dept of Health and Human Services

is receiving $1026158 to serve Travis County

(Austin) to expand efforts in tobacco-free living

active living and healthy eating quality clinical

and other preventive services social and

emotional wellness and healthy and safe

physical environmentswwwcdcgov1052011

Building sustainable healthy

communities Bottom line

Obesity is an environmental problem

Despite progress in genetic research public health advances only will occur when we take the environment seriously

Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment

Until we do this we will not make substantial progress in addressing the epidemic of obesity

Poston amp Foreyt Atherosclerosis 1999

Whatrsquos the best approach

Integrate all sectors of society into community

change interventions

Incorporate

Science amp Technology

Education

FamilyCommunity

Healthcare

Arts amp Entertainment

Law amp Politics

Commerce amp Trade

Sectors of Society

Arts amp Entertainm

ent

Commerce amp Trade

Education

FamilyCommunity

Healthcare

Law amp Politics

Science amp Technology

Project FIT rationale design and baseline characteristics of a school- and community-

based intervention to address physical activity and healthy eating among low-income

elementary school children

Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D

Oh HJ Orth J Randall S Mayfield K Holmes D

Source

Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu

Abstract

BACKGROUND

This paper describes Project FIT a collaboration between the public school system local

health systems physicians neighborhood associations businesses faith-based leaders

community agencies and university researchers to develop a multi-faceted approach to

promote physical activity and healthy eating toward the general goal of preventing and

reducing childhood obesity among children in Grand Rapids MI USA

METHODSDESIGN

There are four overall components to Project FIT school community social marketing and

school staff wellness - all that focus on 1) increasing access to safe and affordable physical

activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)

improving the affordability and availability of nutritious food in the neighborhoods surrounding

the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding

nutrition and physical activity among school staff parents and students 4) impacting the

culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging

dialogue among all community partners to leverage existing programs and introduce new

ones

LONG-TERM WEIGHT MAINTENANCE

Continued consumption of a low-

calorie diet with moderate fat intake

Limited fast food

High levels of physical activity

Phalen et al Obesity 2006 14 710-716

LONG-TERM WEIGHT MAINTENANCE

Daily weighing improved

maintenance of weight loss

particularly when delivered

face to face

Wing et al NEJM 2006 3551563-1571

Most Promising Strategies For

Preventing Weight Regain

Providing multi-component

programs with ongoing

professional contacts

Physical activityexercise

Portion controlmeal replacements

Extending treatment through

weekly or bi-weekly sessions

Pharmacotherapy

Perri Foreyt amp Anton Preventing Weight Regain After Weight Loss 2008

Most Promising Strategies For

Preventing Weight Regain

Extended treatments have shown

promise in promoting adherence to

the behaviors required for the long-

term maintenance of weight loss

Continuous care approach focused

on reasonable long-term objectives

appears appropriate for most

patients

Perri Foreyt amp Anton Preventing Weight Regain After Weight

Loss 2008

An Example of a successful long-term

intervention

The Look AHEAD Study

Does Weight Loss Reduce

Cardiovascular Disease and Death in

Overweight Individuals with Diabetes

bull Action for HEAlth in Diabetes

bull Objective to examine in overweight

persons with Type 2 Diabetes the long-

term effects of an intensive lifestyle

intervention program compared to

diabetes education and support

bull 16 Centers

bull 5145 overweight volunteers with

diabetes

Look AHEAD

Look AHEAD

Primary End Point Composite

bull Cardiovascular death (including fatal

myocardial infarction and stroke)

bull Non-fatal myocardial infarction

bull Non-fatal stroke

Winston-Salem

Baltimore

Philadelphia

New York

Providence

Boston

Clinical Site Coordinating Center

Clinical Sites

Seattle

Los Angeles

San AntonioHouston

Baton Rouge

Minneapolis

Memphis

Birmingham

Pittsburgh

Denver

Phoenix

Look AHEADParticipants

101100Baseline weight (kg)

589586Age (years)

9496Attended 1 year exam

360359Baseline BMI

1514Insulin Users

3737Minority

6059Women

(N=2574)(N=2630)

DSELifestyle

p lt 0004

Look AHEAD

Study Interventions

bull Diabetes support and education - DSE (control group)

bull Lifestyle intervention ndash ILI (treatment group)

Look AHEAD

Lifestyle Intervention

Goals

bull 7 weight loss for the group (10

for individual)

bull 175 minutes of moderate intensity

activity

Look AHEAD

Lifestyle Intervention

bull Diet

ndash ADA NCEP (lt 30 fat lt 10 sat fat

gt15 protein)

ndash 1200-1500 (if weight lt250lbs)

ndash 1500-1800 (if weight gt250lbs)

ndash During first 4 weeks to 4 months portion

control (liquid meal replacements or

structured meal plan)

Look AHEAD

Lifestyle Intervention

bull Physical Activity

ndash unsupervised

ndash 175 minutes moderate intensityweek

ndash 5 daysweek

ndash walking

Weight Loss at 1-Year

-9

ILI 0

-1

-2

-3

-4

-5

-6

-7

-8

DSE

p lt 00001

W

eig

ht

Chan

ge

86

07

The Look AHEAD Research Group Diabetes Care 2007

Reduction in Initial Weight by Gender

N=872

N=1229N=1197

N=830

-12

-10

-8

-6

-4

-2

0

0 2 4 6 8 10 12

Months

R

ed

uctio

n in

In

itia

l W

eig

ht

Men

Women

Plt0001

The Look AHEAD Research Group Diabetes Care 2007

Fitness Change () at 1-Year

0

5

10

15

20

25

Mean

Fitness C

hange

Unadjusted

Plt0001Adjusted for 1 Year

Weight Change Plt0001

58

209

108

159

DSE ILI ILIDSE

The Look AHEAD Research Group Diabetes Care 2007

1-Year Changes in Markers of

Diabetes Control

Markers of Diabetes

Control ILI DSE P-value

Hemoglobin A1c () BL

Hemoglobin A1c () Y1

Y1 ndash Baseline

725

661

-064

729

715

-014

026

lt0001

lt0001

Fasting glucose (mgdl) BL

Fasting glucose (mgdl) Y1

Y1 ndash Baseline

1519

1304

-215

1536

1464

-72

021

lt0001

lt0001

Diabetes medications BL

Diabetes medications Y1

Y1 ndash Baseline

865

786

-78

865

887

22

093

lt0001

lt0001

1-Year Changes in Markers of

Blood Pressure ControlMarkers of Blood Pressure

Control ILI DSE P-value

Systolic BP (mmHg) BL

Systolic BP (mmHg) Y1

Y1 ndash Baseline

1282

1214

-68

1294

1266

-28

026

lt0001

lt0001

Diastolic BP (mmHg) BL

Diastolic BP (mmHg) Y1

Y1 ndash Baseline

699

670

-30

704

686

-18

011

lt0001

lt0001

Antihypertensive medications BL

Antihypertensive medications Y1

Y1 ndash Baseline

753

752

-01

737

759

22

023

054

002

1-Year Changes in Markers of Lipid

Control

Markers of Lipid Control ILI DSE P-value

LDL-cholesterol (mgdl) BL

LDL-cholesterol (mgdl) Y1

Y1 ndash Baseline

1122

1070

-52

1124

1067

-57

078

074

049

HDL-cholesterol (mgdl) BL

HDL-cholesterol (mgdl) Y1

Y1 ndash Baseline

435

469

34

436

449

14

080

lt0001

lt0001

Triglycerides (mgdl) BL

Triglycerides (mgdl) Y1

Y1 ndash Baseline

1828

1525

-303

1800

1654

-146

038

lt0001

lt0001

Lipid lowering medications BL

Lipid lowering medications Y1

Y1 ndash Baseline

494

530

37

484

578

94

052

lt0001

lt0001

1-Year Changes in Percent of Participants

Meeting ADA Goals

ADA Goal ILI DSE P-value

Hemoglobin A1c lt 7 BL

Hemoglobin A1c lt 7 Y1

Y1 ndash Baseline

463

727

264

454

508

54

050

lt0001

lt0001

Blood pressure lt 13080 mmHg BL

Blood pressure lt 13080 mmHg Y1

Y1 ndash Baseline

535

686

151

499

570

70

001

lt0001

lt0001

LDL-cholesterol lt 100 mgdl BL

LDL-cholesterol lt 100 mgdl Y1

Y1 ndash Baseline

371

438

67

369

449

80

087

045

034

All three goals BL

All three goals Y1

Y1 ndash Baseline

108

236

128

95

160

65

013

lt0001

lt0001

Mean Changes in Weight Fitness amp BP

Averaged Over Four Years

DSE

Mean

ILI

Mean

P-value

Weight Loss

( initial wt)

-088 -615 lt 00001

Fitness

( METS)

196 1274 lt00001

HbA1c -009 -036 lt 00001

SBP (mm Hg) -297 -533 lt 00001

DBP (mm Hg) -248 -292 0012

Look AHEAD Research Group Arch Int Med 2010

Mean Changes in Lipid Profile

Averaged Over Four Years

DSE

Mean

ILI

Mean

P-value

HDL (mgdl) 197 367 lt00001

TG (mgdl) -1975 -2556 00006

LDL (mgdl) -1284 -1127 0009

LDL (mgdl)

(Adjusting for

medication use)

-922 -875 042

Look AHEAD Research Group Arch Int Med 2010

Percent () Completing Outcome

Measures at Years 1-4

Intervention Group

(ILI)

Year 1 971

Year 2 949

Year 3 940

Year 4 941

Comparison Group

(DSE)

Year 1 957

Year 2 935

Year 3 938

Year 4 931

Look AHEAD Summary

ILI had significantly greater improvements than DSE in all CVD risk factors averaged across 4 years (except LDL-C)

There may be long-term beneficial effects from this 4-year period in which ILI subjects have been exposed to lower CVD risk factors

Longer follow-ups will determine whether these lowered CVD risk factors can be maintained amp whether lifestyle intervention has positive effects on CVD morbidity amp mortality

Mary J

Female

White

56 years old at start of Look AHEAD

study

Past Medical History Type 2 diabetes

overweight diverticulosis arthritis

sleep apnea back pain

Mary J

bullLong term strugglesbull Helping youngest daughter with

personal issues and children

bull Rotator cuff problems

bull Degenerative disks in back

bull Rheumatoid arthritis

bull Diabetes

bull Physically demanding job

bull Financial struggles

Pounds

Years

82007 grandkids enter pre-school

Catherine L

Female

White

47 years old at start of Look AHEAD

study

Past Medical History Type 2 diabetes

overweight high blood pressure

hypothyroidism back pain

Catherine L

Long term struggles

bull Motherrsquos declining health and death

bull Multiple serious injuries

bull Sudden death of sister

bull Death of step-father

bull Declining economy

bull Children living at home

Pounds

Years

Realistic Management Goals

5-10 weight loss

Health energy and fitness

Well-being and self-esteem

Mood and appearance

Functional and recreational

activity

Key Elements

Focus on health and energy

Food and physical activity diaries

Gradual increase in physical activity

Gradual reduction in dietary fat

No feelings of food deprivation

Social support groups

Recommended Strategies for Building

Sustainable Healthy Communities

Overview from USA

Promote the availability of affordable healthy

food and beverages

Support healthy food and beverage choices

Encourage breastfeeding

Encourage physical activity or limit sedentary

activity among children amp youth

Create safe communities that support physical

activity

Encourage communities to organize for change

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Increase the availability of healthier food and

beverage choices in public service venues (eg

schools city amp county buildings etc)

--Insufficient evidence in school-based programs

--Associations suggest availability amp increased

consumption

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve availability of affordable healthier

food amp beverage choices in public service

venues

--Reducing the cost of healthier foods

increases their purchase

--Providing coupons redeemable for

healthier foods increases their purchase

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve geographic availability of

supermarkets in underserved areas

-- Greater access to nearby supermarkets is

associated with healthier eating behaviors

-- Increasing the number of supermarkets in

underserved neighborhoods increased

real estate values increased economic

activity amp employment amp resulted in lower

food prices

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Provide incentives to food retailers to locate in

andor offer healthier food choices in

underserved areas

-- Presence of retail venues that provide healthier

foods is associated with better nutrition

-- Greater availability of supermarkets was

associated with lower adolescent BMI scores

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Improve availability of mechanisms for

purchasing foods from farms

--Evidence supporting a direct link between

purchasing food from farms amp improved diet is

limited

--Two studies of initiatives to encourage

participation in farmersrsquo market showed

increased intention to eat more fruits amp

vegetables but no direct evidence

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Provide incentives for the production

distribution and procurement of foods from local

farms

--No evidence has been published to link local

food production amp health outcomes

--There is a current study exploring the potential

nutritional amp health benefits of eating locally

grown foods

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Restrict availability of less healthy foods amp

beverages in public service venues

--No peer-reviewed studies examined the impact

designed to restrict availability of less healthy

foods in public service venues

--21 states have policies that restrict the sale of

competitive foods in schools beyond USDA

regulations however no studies have evaluated

the impact of the policies

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Institute smaller portion size options in public

service venues

--Evidence is lacking to demonstrate effectiveness

of population-based interventions aimed at

reducing portion sizes in public service venues

--Evidence from clinical studies in laboratories

demonstrates decreasing portion sizes

decreases energy intake

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Limit advertisements of less healthy foods amp

beverages

--Little evidence is available regarding the impact

of restricting advertising on purchasing amp

consumption of less healthy foods

--Cross-sectional time-series studies of tobacco-

control efforts suggest an association between

advertising bans amp decreased tobacco

consumption

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Discourage consumption of sugar-sweetened

beverages

--One longitudinal study of a school-based

intervention among Native-American high school

students showed a substantial reduction in

sugar-sweetened beverages over a 3-year

period

--A RCT of a home-based intervention that

eliminated sugar-sweetened beverages showed

reduction in BMI scores

Recommended Community Strategies Strategies to encourage breastfeeding

Increase support for breastfeeding

--Evidence directly linking environmental

interventions that support breastfeeding with

obesity-related outcomes is lacking

--Epidemiologic studies indicate that breastfeeding

helps prevent pediatric obesity

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Require physical education in schools

--14 studies have demonstrated that school-based

PE was effective in increasing levels of physical

activity and improving physical fitness

--Minimum of 150 minwk in elementary schools

225 minwk in middle schools and high schools

throughout the school year as recommended by

NASPE

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Increase opportunities for extracurricular

physical activity

--Participation in after-school programs increased

studentsrsquo level of physical activity amp improved

obesity-related outcomes (improved CV fitness

reduced body fat)

--2 pilot studies providing extracurricular physical

activity showed increased levels of PA amp

decreased sedentary behavior

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Reduce screen time in public service venues

--A school-based RCT indicated that children who

reduced their television videotape amp video

game use had significant decrease in BMI tricep

skin fold thickness amp waist circumference

compared to controls

--Spending less time watching television is

associated with increased physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Improve access to outdoor recreational

facilities

--Review of 108 studies indicated that access to facilities

and programs for recreation near their homes amp time

spent outdoors correlated positively with increased

physical activity among childrenamp adults

--Perceptions that footpaths are safe for walking was

significantly associated with adults being classified as

physically active at a level sufficient for health benefits

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting

bicycling

--Longitudinal intervention studies have

demonstrated that improving bicycling

infrastructure is associated with increased

frequency of bicycling

--Cross-sectional studies indicated a significant

association between bicycling infrastructure amp

frequency of biking

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting walking

--Reviews of cross-sectional studies of

environmental correlates of physical activity amp

walking generally find a positive association

between infrastructure supportive of walking amp

physical activity

--Identifying amp creating safe routes to school

together with educational components

increased the number of students walking to

school

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Locating schools within easy walking

distance of residential areas

--Community-scale urban design amp land use policies amp

practices including locating schools stores workplaces

amp recreation areas close to residential areas are

effective in facilitating an increase in levels of physical

activity

--Majority of efforts to encourage walking to school involve

improving the routes rather than improving the location

of schools

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Improve access to public transportation

--Insufficient evidence exists to determine

effectiveness of transportation policies in

increasing the level of physical activity or

improving fitness

--1 study indicated that 29 of individuals who

walk to and from public transit achieve at least

30 minutes of daily physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Zone for mixed-use development

--Allows residential commercial institutional amp

other public land uses to be located in close

proximity to one another

--Studies using correlation analyses amp regression

models indicated that mixed land use was

associated with increased walking amp cycling

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance personal safety in areas where

persons are or could be physically active

--Cross-sectional studies have demonstrated a

negative relationship between crime rates andor

perceived safety amp physical activity in

neighborhoods

--Few intervention studies have evaluated the

impact of policies amp practices to improve

personal safety on physical activity

Geospatial Mapping Linking Urban

Environments to Health Risk

Measure association between environmental variables amp health risk factors

Assess relationships between variables at different levels of analysis

Used in conjunction with linear analyses

Our Community Environmental Model

of Obesity

Community Factors

Poverty

Crime

Grocery Quality

Restaurants

Parks

Sidewalks

Fast Food Outlets

Recreational

Facilities

Individual Factors

Dietary Intake

Physical Activity

Genetics

Family History

StressCoping

Eating Disorders

Psychological

Problems

Weight

Status

Chosen Neighborhoods

Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped

We then matched census-block groups within the income groups by population density and percentage of minority representation

One matched block group per income level was randomly selected

Prevalence of Obesity in

Block-Groups

0

5

10

15

20

25

30

35

40

45

50

Ag

e-a

dju

sted

Ob

esit

y P

rev

ale

nce

(

)

High-Income Low-Income

Age-standardized to the 1990 US Census

Density of Environmental Factors in the

Community Contributes to a ldquoToxicrdquo

Obesity Environment

0

2

4

6

8

10

12

14

16

18

Fast-food Convenience Store Bars

Den

sity

10

00

perso

ns

High-Income Low-Income

COMMUNITYrsquoS PERCEPTION OF SAFETY

0

5

10

15

20

25

30

35

40

Daytime Nighttime

Perc

en

t (

) F

eeli

ng

So

mew

hat

Safe

or

Un

safe

Low-Income High-Income

Percent Substandard (or worse) Housing

or Ground Conditions

of Residential Properties

0

10

20

30

Structural Grounds

Perc

en

t (

)

Low-Income High-Income

CONCLUSIONS

These data suggest that the higher

frequency of outlets providing

calorically-dense foods and alcohol may

contribute to greater obesity prevalence

in residents of low-income communities

More research is needed to thoroughly

document environmental determinants

of health and obesity

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

From 1994-1998 HUD randomly assigned

4498 women with children living in public

housing in high-poverty urban census

tracts to one of three groups (1) housing

vouchers redeemable only if they moved

to a low-poverty census tract (2)

unrestricted vouchers or (3) control group

(no vouchers)

Ludwig et al NEJM 201136516

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

10-12 year follow-up showed modest but

potentially important reductions in the

prevalence of extreme obesity amp diabetes in the

group moving from a neighborhood with high

poverty on one of low poverty compared to the

control group

No differences between the group receiving

traditional vouchers amp the control group

ldquoNeighborhoods matterrdquo

Ludwig et al NEJM 201136516

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance traffic safety in areas where

persons are or could be physically active

--Community-scale urban design amp land use policies to

promote physical activity including design components

to improve street lighting infrastructure projects to

increase safety of pedestrian street crossing and use of

traffic calming approaches such as speed humps amp

traffic circles are effective in increasing physical activity

--Both community-scale amp street-scale policies amp practices

are effective in increasing physical activity

Recommended Community Strategies Encourage Communities to Organize for Change

Participate in community coalitions or

partnerships to address obesity

--Little evidence is available to determine the

impact of community coalitions on obesity

prevention

--The presence of anti-smoking community

coalitions has been associated with lower rates

of tobacco consumption

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

$103 million awarded to 61 states and

communities including state amp local government

agencies tribes amp territories amp state amp local non-

profit organizations

To build capacity to implement changes for

community prevention efforts to ensure long-

term success

To implement evidence-based and practice-

based programs to improve health amp wellness

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Priority areas are

Tobacco-free living

Active living and healthy eating

Evidence-based quality clinical and other

preventive health services for prevention

and control of high blood pressure and

high cholesterol

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Applicants proposed specific activities in

line with their chosen priority areas in their

applications

Grantee activities will not be finalized until

plans are negotiated with CDC by early

2012

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Capacity-Building Award

The Confederated Tribes of The Chehalis

Reservation is receiving a $498663 planning

award to build capacity to support healthy

lifestyles among their tribal population of 1500

in Washington State

Work will target tobacco-free living active living

and healthy eating and quality clinical and other

healthy serviceswwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Implementation Award

Austin TX Dept of Health and Human Services

is receiving $1026158 to serve Travis County

(Austin) to expand efforts in tobacco-free living

active living and healthy eating quality clinical

and other preventive services social and

emotional wellness and healthy and safe

physical environmentswwwcdcgov1052011

Building sustainable healthy

communities Bottom line

Obesity is an environmental problem

Despite progress in genetic research public health advances only will occur when we take the environment seriously

Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment

Until we do this we will not make substantial progress in addressing the epidemic of obesity

Poston amp Foreyt Atherosclerosis 1999

Whatrsquos the best approach

Integrate all sectors of society into community

change interventions

Incorporate

Science amp Technology

Education

FamilyCommunity

Healthcare

Arts amp Entertainment

Law amp Politics

Commerce amp Trade

Sectors of Society

Arts amp Entertainm

ent

Commerce amp Trade

Education

FamilyCommunity

Healthcare

Law amp Politics

Science amp Technology

Project FIT rationale design and baseline characteristics of a school- and community-

based intervention to address physical activity and healthy eating among low-income

elementary school children

Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D

Oh HJ Orth J Randall S Mayfield K Holmes D

Source

Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu

Abstract

BACKGROUND

This paper describes Project FIT a collaboration between the public school system local

health systems physicians neighborhood associations businesses faith-based leaders

community agencies and university researchers to develop a multi-faceted approach to

promote physical activity and healthy eating toward the general goal of preventing and

reducing childhood obesity among children in Grand Rapids MI USA

METHODSDESIGN

There are four overall components to Project FIT school community social marketing and

school staff wellness - all that focus on 1) increasing access to safe and affordable physical

activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)

improving the affordability and availability of nutritious food in the neighborhoods surrounding

the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding

nutrition and physical activity among school staff parents and students 4) impacting the

culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging

dialogue among all community partners to leverage existing programs and introduce new

ones

LONG-TERM WEIGHT MAINTENANCE

Daily weighing improved

maintenance of weight loss

particularly when delivered

face to face

Wing et al NEJM 2006 3551563-1571

Most Promising Strategies For

Preventing Weight Regain

Providing multi-component

programs with ongoing

professional contacts

Physical activityexercise

Portion controlmeal replacements

Extending treatment through

weekly or bi-weekly sessions

Pharmacotherapy

Perri Foreyt amp Anton Preventing Weight Regain After Weight Loss 2008

Most Promising Strategies For

Preventing Weight Regain

Extended treatments have shown

promise in promoting adherence to

the behaviors required for the long-

term maintenance of weight loss

Continuous care approach focused

on reasonable long-term objectives

appears appropriate for most

patients

Perri Foreyt amp Anton Preventing Weight Regain After Weight

Loss 2008

An Example of a successful long-term

intervention

The Look AHEAD Study

Does Weight Loss Reduce

Cardiovascular Disease and Death in

Overweight Individuals with Diabetes

bull Action for HEAlth in Diabetes

bull Objective to examine in overweight

persons with Type 2 Diabetes the long-

term effects of an intensive lifestyle

intervention program compared to

diabetes education and support

bull 16 Centers

bull 5145 overweight volunteers with

diabetes

Look AHEAD

Look AHEAD

Primary End Point Composite

bull Cardiovascular death (including fatal

myocardial infarction and stroke)

bull Non-fatal myocardial infarction

bull Non-fatal stroke

Winston-Salem

Baltimore

Philadelphia

New York

Providence

Boston

Clinical Site Coordinating Center

Clinical Sites

Seattle

Los Angeles

San AntonioHouston

Baton Rouge

Minneapolis

Memphis

Birmingham

Pittsburgh

Denver

Phoenix

Look AHEADParticipants

101100Baseline weight (kg)

589586Age (years)

9496Attended 1 year exam

360359Baseline BMI

1514Insulin Users

3737Minority

6059Women

(N=2574)(N=2630)

DSELifestyle

p lt 0004

Look AHEAD

Study Interventions

bull Diabetes support and education - DSE (control group)

bull Lifestyle intervention ndash ILI (treatment group)

Look AHEAD

Lifestyle Intervention

Goals

bull 7 weight loss for the group (10

for individual)

bull 175 minutes of moderate intensity

activity

Look AHEAD

Lifestyle Intervention

bull Diet

ndash ADA NCEP (lt 30 fat lt 10 sat fat

gt15 protein)

ndash 1200-1500 (if weight lt250lbs)

ndash 1500-1800 (if weight gt250lbs)

ndash During first 4 weeks to 4 months portion

control (liquid meal replacements or

structured meal plan)

Look AHEAD

Lifestyle Intervention

bull Physical Activity

ndash unsupervised

ndash 175 minutes moderate intensityweek

ndash 5 daysweek

ndash walking

Weight Loss at 1-Year

-9

ILI 0

-1

-2

-3

-4

-5

-6

-7

-8

DSE

p lt 00001

W

eig

ht

Chan

ge

86

07

The Look AHEAD Research Group Diabetes Care 2007

Reduction in Initial Weight by Gender

N=872

N=1229N=1197

N=830

-12

-10

-8

-6

-4

-2

0

0 2 4 6 8 10 12

Months

R

ed

uctio

n in

In

itia

l W

eig

ht

Men

Women

Plt0001

The Look AHEAD Research Group Diabetes Care 2007

Fitness Change () at 1-Year

0

5

10

15

20

25

Mean

Fitness C

hange

Unadjusted

Plt0001Adjusted for 1 Year

Weight Change Plt0001

58

209

108

159

DSE ILI ILIDSE

The Look AHEAD Research Group Diabetes Care 2007

1-Year Changes in Markers of

Diabetes Control

Markers of Diabetes

Control ILI DSE P-value

Hemoglobin A1c () BL

Hemoglobin A1c () Y1

Y1 ndash Baseline

725

661

-064

729

715

-014

026

lt0001

lt0001

Fasting glucose (mgdl) BL

Fasting glucose (mgdl) Y1

Y1 ndash Baseline

1519

1304

-215

1536

1464

-72

021

lt0001

lt0001

Diabetes medications BL

Diabetes medications Y1

Y1 ndash Baseline

865

786

-78

865

887

22

093

lt0001

lt0001

1-Year Changes in Markers of

Blood Pressure ControlMarkers of Blood Pressure

Control ILI DSE P-value

Systolic BP (mmHg) BL

Systolic BP (mmHg) Y1

Y1 ndash Baseline

1282

1214

-68

1294

1266

-28

026

lt0001

lt0001

Diastolic BP (mmHg) BL

Diastolic BP (mmHg) Y1

Y1 ndash Baseline

699

670

-30

704

686

-18

011

lt0001

lt0001

Antihypertensive medications BL

Antihypertensive medications Y1

Y1 ndash Baseline

753

752

-01

737

759

22

023

054

002

1-Year Changes in Markers of Lipid

Control

Markers of Lipid Control ILI DSE P-value

LDL-cholesterol (mgdl) BL

LDL-cholesterol (mgdl) Y1

Y1 ndash Baseline

1122

1070

-52

1124

1067

-57

078

074

049

HDL-cholesterol (mgdl) BL

HDL-cholesterol (mgdl) Y1

Y1 ndash Baseline

435

469

34

436

449

14

080

lt0001

lt0001

Triglycerides (mgdl) BL

Triglycerides (mgdl) Y1

Y1 ndash Baseline

1828

1525

-303

1800

1654

-146

038

lt0001

lt0001

Lipid lowering medications BL

Lipid lowering medications Y1

Y1 ndash Baseline

494

530

37

484

578

94

052

lt0001

lt0001

1-Year Changes in Percent of Participants

Meeting ADA Goals

ADA Goal ILI DSE P-value

Hemoglobin A1c lt 7 BL

Hemoglobin A1c lt 7 Y1

Y1 ndash Baseline

463

727

264

454

508

54

050

lt0001

lt0001

Blood pressure lt 13080 mmHg BL

Blood pressure lt 13080 mmHg Y1

Y1 ndash Baseline

535

686

151

499

570

70

001

lt0001

lt0001

LDL-cholesterol lt 100 mgdl BL

LDL-cholesterol lt 100 mgdl Y1

Y1 ndash Baseline

371

438

67

369

449

80

087

045

034

All three goals BL

All three goals Y1

Y1 ndash Baseline

108

236

128

95

160

65

013

lt0001

lt0001

Mean Changes in Weight Fitness amp BP

Averaged Over Four Years

DSE

Mean

ILI

Mean

P-value

Weight Loss

( initial wt)

-088 -615 lt 00001

Fitness

( METS)

196 1274 lt00001

HbA1c -009 -036 lt 00001

SBP (mm Hg) -297 -533 lt 00001

DBP (mm Hg) -248 -292 0012

Look AHEAD Research Group Arch Int Med 2010

Mean Changes in Lipid Profile

Averaged Over Four Years

DSE

Mean

ILI

Mean

P-value

HDL (mgdl) 197 367 lt00001

TG (mgdl) -1975 -2556 00006

LDL (mgdl) -1284 -1127 0009

LDL (mgdl)

(Adjusting for

medication use)

-922 -875 042

Look AHEAD Research Group Arch Int Med 2010

Percent () Completing Outcome

Measures at Years 1-4

Intervention Group

(ILI)

Year 1 971

Year 2 949

Year 3 940

Year 4 941

Comparison Group

(DSE)

Year 1 957

Year 2 935

Year 3 938

Year 4 931

Look AHEAD Summary

ILI had significantly greater improvements than DSE in all CVD risk factors averaged across 4 years (except LDL-C)

There may be long-term beneficial effects from this 4-year period in which ILI subjects have been exposed to lower CVD risk factors

Longer follow-ups will determine whether these lowered CVD risk factors can be maintained amp whether lifestyle intervention has positive effects on CVD morbidity amp mortality

Mary J

Female

White

56 years old at start of Look AHEAD

study

Past Medical History Type 2 diabetes

overweight diverticulosis arthritis

sleep apnea back pain

Mary J

bullLong term strugglesbull Helping youngest daughter with

personal issues and children

bull Rotator cuff problems

bull Degenerative disks in back

bull Rheumatoid arthritis

bull Diabetes

bull Physically demanding job

bull Financial struggles

Pounds

Years

82007 grandkids enter pre-school

Catherine L

Female

White

47 years old at start of Look AHEAD

study

Past Medical History Type 2 diabetes

overweight high blood pressure

hypothyroidism back pain

Catherine L

Long term struggles

bull Motherrsquos declining health and death

bull Multiple serious injuries

bull Sudden death of sister

bull Death of step-father

bull Declining economy

bull Children living at home

Pounds

Years

Realistic Management Goals

5-10 weight loss

Health energy and fitness

Well-being and self-esteem

Mood and appearance

Functional and recreational

activity

Key Elements

Focus on health and energy

Food and physical activity diaries

Gradual increase in physical activity

Gradual reduction in dietary fat

No feelings of food deprivation

Social support groups

Recommended Strategies for Building

Sustainable Healthy Communities

Overview from USA

Promote the availability of affordable healthy

food and beverages

Support healthy food and beverage choices

Encourage breastfeeding

Encourage physical activity or limit sedentary

activity among children amp youth

Create safe communities that support physical

activity

Encourage communities to organize for change

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Increase the availability of healthier food and

beverage choices in public service venues (eg

schools city amp county buildings etc)

--Insufficient evidence in school-based programs

--Associations suggest availability amp increased

consumption

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve availability of affordable healthier

food amp beverage choices in public service

venues

--Reducing the cost of healthier foods

increases their purchase

--Providing coupons redeemable for

healthier foods increases their purchase

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve geographic availability of

supermarkets in underserved areas

-- Greater access to nearby supermarkets is

associated with healthier eating behaviors

-- Increasing the number of supermarkets in

underserved neighborhoods increased

real estate values increased economic

activity amp employment amp resulted in lower

food prices

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Provide incentives to food retailers to locate in

andor offer healthier food choices in

underserved areas

-- Presence of retail venues that provide healthier

foods is associated with better nutrition

-- Greater availability of supermarkets was

associated with lower adolescent BMI scores

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Improve availability of mechanisms for

purchasing foods from farms

--Evidence supporting a direct link between

purchasing food from farms amp improved diet is

limited

--Two studies of initiatives to encourage

participation in farmersrsquo market showed

increased intention to eat more fruits amp

vegetables but no direct evidence

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Provide incentives for the production

distribution and procurement of foods from local

farms

--No evidence has been published to link local

food production amp health outcomes

--There is a current study exploring the potential

nutritional amp health benefits of eating locally

grown foods

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Restrict availability of less healthy foods amp

beverages in public service venues

--No peer-reviewed studies examined the impact

designed to restrict availability of less healthy

foods in public service venues

--21 states have policies that restrict the sale of

competitive foods in schools beyond USDA

regulations however no studies have evaluated

the impact of the policies

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Institute smaller portion size options in public

service venues

--Evidence is lacking to demonstrate effectiveness

of population-based interventions aimed at

reducing portion sizes in public service venues

--Evidence from clinical studies in laboratories

demonstrates decreasing portion sizes

decreases energy intake

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Limit advertisements of less healthy foods amp

beverages

--Little evidence is available regarding the impact

of restricting advertising on purchasing amp

consumption of less healthy foods

--Cross-sectional time-series studies of tobacco-

control efforts suggest an association between

advertising bans amp decreased tobacco

consumption

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Discourage consumption of sugar-sweetened

beverages

--One longitudinal study of a school-based

intervention among Native-American high school

students showed a substantial reduction in

sugar-sweetened beverages over a 3-year

period

--A RCT of a home-based intervention that

eliminated sugar-sweetened beverages showed

reduction in BMI scores

Recommended Community Strategies Strategies to encourage breastfeeding

Increase support for breastfeeding

--Evidence directly linking environmental

interventions that support breastfeeding with

obesity-related outcomes is lacking

--Epidemiologic studies indicate that breastfeeding

helps prevent pediatric obesity

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Require physical education in schools

--14 studies have demonstrated that school-based

PE was effective in increasing levels of physical

activity and improving physical fitness

--Minimum of 150 minwk in elementary schools

225 minwk in middle schools and high schools

throughout the school year as recommended by

NASPE

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Increase opportunities for extracurricular

physical activity

--Participation in after-school programs increased

studentsrsquo level of physical activity amp improved

obesity-related outcomes (improved CV fitness

reduced body fat)

--2 pilot studies providing extracurricular physical

activity showed increased levels of PA amp

decreased sedentary behavior

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Reduce screen time in public service venues

--A school-based RCT indicated that children who

reduced their television videotape amp video

game use had significant decrease in BMI tricep

skin fold thickness amp waist circumference

compared to controls

--Spending less time watching television is

associated with increased physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Improve access to outdoor recreational

facilities

--Review of 108 studies indicated that access to facilities

and programs for recreation near their homes amp time

spent outdoors correlated positively with increased

physical activity among childrenamp adults

--Perceptions that footpaths are safe for walking was

significantly associated with adults being classified as

physically active at a level sufficient for health benefits

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting

bicycling

--Longitudinal intervention studies have

demonstrated that improving bicycling

infrastructure is associated with increased

frequency of bicycling

--Cross-sectional studies indicated a significant

association between bicycling infrastructure amp

frequency of biking

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting walking

--Reviews of cross-sectional studies of

environmental correlates of physical activity amp

walking generally find a positive association

between infrastructure supportive of walking amp

physical activity

--Identifying amp creating safe routes to school

together with educational components

increased the number of students walking to

school

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Locating schools within easy walking

distance of residential areas

--Community-scale urban design amp land use policies amp

practices including locating schools stores workplaces

amp recreation areas close to residential areas are

effective in facilitating an increase in levels of physical

activity

--Majority of efforts to encourage walking to school involve

improving the routes rather than improving the location

of schools

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Improve access to public transportation

--Insufficient evidence exists to determine

effectiveness of transportation policies in

increasing the level of physical activity or

improving fitness

--1 study indicated that 29 of individuals who

walk to and from public transit achieve at least

30 minutes of daily physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Zone for mixed-use development

--Allows residential commercial institutional amp

other public land uses to be located in close

proximity to one another

--Studies using correlation analyses amp regression

models indicated that mixed land use was

associated with increased walking amp cycling

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance personal safety in areas where

persons are or could be physically active

--Cross-sectional studies have demonstrated a

negative relationship between crime rates andor

perceived safety amp physical activity in

neighborhoods

--Few intervention studies have evaluated the

impact of policies amp practices to improve

personal safety on physical activity

Geospatial Mapping Linking Urban

Environments to Health Risk

Measure association between environmental variables amp health risk factors

Assess relationships between variables at different levels of analysis

Used in conjunction with linear analyses

Our Community Environmental Model

of Obesity

Community Factors

Poverty

Crime

Grocery Quality

Restaurants

Parks

Sidewalks

Fast Food Outlets

Recreational

Facilities

Individual Factors

Dietary Intake

Physical Activity

Genetics

Family History

StressCoping

Eating Disorders

Psychological

Problems

Weight

Status

Chosen Neighborhoods

Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped

We then matched census-block groups within the income groups by population density and percentage of minority representation

One matched block group per income level was randomly selected

Prevalence of Obesity in

Block-Groups

0

5

10

15

20

25

30

35

40

45

50

Ag

e-a

dju

sted

Ob

esit

y P

rev

ale

nce

(

)

High-Income Low-Income

Age-standardized to the 1990 US Census

Density of Environmental Factors in the

Community Contributes to a ldquoToxicrdquo

Obesity Environment

0

2

4

6

8

10

12

14

16

18

Fast-food Convenience Store Bars

Den

sity

10

00

perso

ns

High-Income Low-Income

COMMUNITYrsquoS PERCEPTION OF SAFETY

0

5

10

15

20

25

30

35

40

Daytime Nighttime

Perc

en

t (

) F

eeli

ng

So

mew

hat

Safe

or

Un

safe

Low-Income High-Income

Percent Substandard (or worse) Housing

or Ground Conditions

of Residential Properties

0

10

20

30

Structural Grounds

Perc

en

t (

)

Low-Income High-Income

CONCLUSIONS

These data suggest that the higher

frequency of outlets providing

calorically-dense foods and alcohol may

contribute to greater obesity prevalence

in residents of low-income communities

More research is needed to thoroughly

document environmental determinants

of health and obesity

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

From 1994-1998 HUD randomly assigned

4498 women with children living in public

housing in high-poverty urban census

tracts to one of three groups (1) housing

vouchers redeemable only if they moved

to a low-poverty census tract (2)

unrestricted vouchers or (3) control group

(no vouchers)

Ludwig et al NEJM 201136516

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

10-12 year follow-up showed modest but

potentially important reductions in the

prevalence of extreme obesity amp diabetes in the

group moving from a neighborhood with high

poverty on one of low poverty compared to the

control group

No differences between the group receiving

traditional vouchers amp the control group

ldquoNeighborhoods matterrdquo

Ludwig et al NEJM 201136516

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance traffic safety in areas where

persons are or could be physically active

--Community-scale urban design amp land use policies to

promote physical activity including design components

to improve street lighting infrastructure projects to

increase safety of pedestrian street crossing and use of

traffic calming approaches such as speed humps amp

traffic circles are effective in increasing physical activity

--Both community-scale amp street-scale policies amp practices

are effective in increasing physical activity

Recommended Community Strategies Encourage Communities to Organize for Change

Participate in community coalitions or

partnerships to address obesity

--Little evidence is available to determine the

impact of community coalitions on obesity

prevention

--The presence of anti-smoking community

coalitions has been associated with lower rates

of tobacco consumption

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

$103 million awarded to 61 states and

communities including state amp local government

agencies tribes amp territories amp state amp local non-

profit organizations

To build capacity to implement changes for

community prevention efforts to ensure long-

term success

To implement evidence-based and practice-

based programs to improve health amp wellness

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Priority areas are

Tobacco-free living

Active living and healthy eating

Evidence-based quality clinical and other

preventive health services for prevention

and control of high blood pressure and

high cholesterol

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Applicants proposed specific activities in

line with their chosen priority areas in their

applications

Grantee activities will not be finalized until

plans are negotiated with CDC by early

2012

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Capacity-Building Award

The Confederated Tribes of The Chehalis

Reservation is receiving a $498663 planning

award to build capacity to support healthy

lifestyles among their tribal population of 1500

in Washington State

Work will target tobacco-free living active living

and healthy eating and quality clinical and other

healthy serviceswwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Implementation Award

Austin TX Dept of Health and Human Services

is receiving $1026158 to serve Travis County

(Austin) to expand efforts in tobacco-free living

active living and healthy eating quality clinical

and other preventive services social and

emotional wellness and healthy and safe

physical environmentswwwcdcgov1052011

Building sustainable healthy

communities Bottom line

Obesity is an environmental problem

Despite progress in genetic research public health advances only will occur when we take the environment seriously

Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment

Until we do this we will not make substantial progress in addressing the epidemic of obesity

Poston amp Foreyt Atherosclerosis 1999

Whatrsquos the best approach

Integrate all sectors of society into community

change interventions

Incorporate

Science amp Technology

Education

FamilyCommunity

Healthcare

Arts amp Entertainment

Law amp Politics

Commerce amp Trade

Sectors of Society

Arts amp Entertainm

ent

Commerce amp Trade

Education

FamilyCommunity

Healthcare

Law amp Politics

Science amp Technology

Project FIT rationale design and baseline characteristics of a school- and community-

based intervention to address physical activity and healthy eating among low-income

elementary school children

Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D

Oh HJ Orth J Randall S Mayfield K Holmes D

Source

Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu

Abstract

BACKGROUND

This paper describes Project FIT a collaboration between the public school system local

health systems physicians neighborhood associations businesses faith-based leaders

community agencies and university researchers to develop a multi-faceted approach to

promote physical activity and healthy eating toward the general goal of preventing and

reducing childhood obesity among children in Grand Rapids MI USA

METHODSDESIGN

There are four overall components to Project FIT school community social marketing and

school staff wellness - all that focus on 1) increasing access to safe and affordable physical

activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)

improving the affordability and availability of nutritious food in the neighborhoods surrounding

the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding

nutrition and physical activity among school staff parents and students 4) impacting the

culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging

dialogue among all community partners to leverage existing programs and introduce new

ones

Most Promising Strategies For

Preventing Weight Regain

Providing multi-component

programs with ongoing

professional contacts

Physical activityexercise

Portion controlmeal replacements

Extending treatment through

weekly or bi-weekly sessions

Pharmacotherapy

Perri Foreyt amp Anton Preventing Weight Regain After Weight Loss 2008

Most Promising Strategies For

Preventing Weight Regain

Extended treatments have shown

promise in promoting adherence to

the behaviors required for the long-

term maintenance of weight loss

Continuous care approach focused

on reasonable long-term objectives

appears appropriate for most

patients

Perri Foreyt amp Anton Preventing Weight Regain After Weight

Loss 2008

An Example of a successful long-term

intervention

The Look AHEAD Study

Does Weight Loss Reduce

Cardiovascular Disease and Death in

Overweight Individuals with Diabetes

bull Action for HEAlth in Diabetes

bull Objective to examine in overweight

persons with Type 2 Diabetes the long-

term effects of an intensive lifestyle

intervention program compared to

diabetes education and support

bull 16 Centers

bull 5145 overweight volunteers with

diabetes

Look AHEAD

Look AHEAD

Primary End Point Composite

bull Cardiovascular death (including fatal

myocardial infarction and stroke)

bull Non-fatal myocardial infarction

bull Non-fatal stroke

Winston-Salem

Baltimore

Philadelphia

New York

Providence

Boston

Clinical Site Coordinating Center

Clinical Sites

Seattle

Los Angeles

San AntonioHouston

Baton Rouge

Minneapolis

Memphis

Birmingham

Pittsburgh

Denver

Phoenix

Look AHEADParticipants

101100Baseline weight (kg)

589586Age (years)

9496Attended 1 year exam

360359Baseline BMI

1514Insulin Users

3737Minority

6059Women

(N=2574)(N=2630)

DSELifestyle

p lt 0004

Look AHEAD

Study Interventions

bull Diabetes support and education - DSE (control group)

bull Lifestyle intervention ndash ILI (treatment group)

Look AHEAD

Lifestyle Intervention

Goals

bull 7 weight loss for the group (10

for individual)

bull 175 minutes of moderate intensity

activity

Look AHEAD

Lifestyle Intervention

bull Diet

ndash ADA NCEP (lt 30 fat lt 10 sat fat

gt15 protein)

ndash 1200-1500 (if weight lt250lbs)

ndash 1500-1800 (if weight gt250lbs)

ndash During first 4 weeks to 4 months portion

control (liquid meal replacements or

structured meal plan)

Look AHEAD

Lifestyle Intervention

bull Physical Activity

ndash unsupervised

ndash 175 minutes moderate intensityweek

ndash 5 daysweek

ndash walking

Weight Loss at 1-Year

-9

ILI 0

-1

-2

-3

-4

-5

-6

-7

-8

DSE

p lt 00001

W

eig

ht

Chan

ge

86

07

The Look AHEAD Research Group Diabetes Care 2007

Reduction in Initial Weight by Gender

N=872

N=1229N=1197

N=830

-12

-10

-8

-6

-4

-2

0

0 2 4 6 8 10 12

Months

R

ed

uctio

n in

In

itia

l W

eig

ht

Men

Women

Plt0001

The Look AHEAD Research Group Diabetes Care 2007

Fitness Change () at 1-Year

0

5

10

15

20

25

Mean

Fitness C

hange

Unadjusted

Plt0001Adjusted for 1 Year

Weight Change Plt0001

58

209

108

159

DSE ILI ILIDSE

The Look AHEAD Research Group Diabetes Care 2007

1-Year Changes in Markers of

Diabetes Control

Markers of Diabetes

Control ILI DSE P-value

Hemoglobin A1c () BL

Hemoglobin A1c () Y1

Y1 ndash Baseline

725

661

-064

729

715

-014

026

lt0001

lt0001

Fasting glucose (mgdl) BL

Fasting glucose (mgdl) Y1

Y1 ndash Baseline

1519

1304

-215

1536

1464

-72

021

lt0001

lt0001

Diabetes medications BL

Diabetes medications Y1

Y1 ndash Baseline

865

786

-78

865

887

22

093

lt0001

lt0001

1-Year Changes in Markers of

Blood Pressure ControlMarkers of Blood Pressure

Control ILI DSE P-value

Systolic BP (mmHg) BL

Systolic BP (mmHg) Y1

Y1 ndash Baseline

1282

1214

-68

1294

1266

-28

026

lt0001

lt0001

Diastolic BP (mmHg) BL

Diastolic BP (mmHg) Y1

Y1 ndash Baseline

699

670

-30

704

686

-18

011

lt0001

lt0001

Antihypertensive medications BL

Antihypertensive medications Y1

Y1 ndash Baseline

753

752

-01

737

759

22

023

054

002

1-Year Changes in Markers of Lipid

Control

Markers of Lipid Control ILI DSE P-value

LDL-cholesterol (mgdl) BL

LDL-cholesterol (mgdl) Y1

Y1 ndash Baseline

1122

1070

-52

1124

1067

-57

078

074

049

HDL-cholesterol (mgdl) BL

HDL-cholesterol (mgdl) Y1

Y1 ndash Baseline

435

469

34

436

449

14

080

lt0001

lt0001

Triglycerides (mgdl) BL

Triglycerides (mgdl) Y1

Y1 ndash Baseline

1828

1525

-303

1800

1654

-146

038

lt0001

lt0001

Lipid lowering medications BL

Lipid lowering medications Y1

Y1 ndash Baseline

494

530

37

484

578

94

052

lt0001

lt0001

1-Year Changes in Percent of Participants

Meeting ADA Goals

ADA Goal ILI DSE P-value

Hemoglobin A1c lt 7 BL

Hemoglobin A1c lt 7 Y1

Y1 ndash Baseline

463

727

264

454

508

54

050

lt0001

lt0001

Blood pressure lt 13080 mmHg BL

Blood pressure lt 13080 mmHg Y1

Y1 ndash Baseline

535

686

151

499

570

70

001

lt0001

lt0001

LDL-cholesterol lt 100 mgdl BL

LDL-cholesterol lt 100 mgdl Y1

Y1 ndash Baseline

371

438

67

369

449

80

087

045

034

All three goals BL

All three goals Y1

Y1 ndash Baseline

108

236

128

95

160

65

013

lt0001

lt0001

Mean Changes in Weight Fitness amp BP

Averaged Over Four Years

DSE

Mean

ILI

Mean

P-value

Weight Loss

( initial wt)

-088 -615 lt 00001

Fitness

( METS)

196 1274 lt00001

HbA1c -009 -036 lt 00001

SBP (mm Hg) -297 -533 lt 00001

DBP (mm Hg) -248 -292 0012

Look AHEAD Research Group Arch Int Med 2010

Mean Changes in Lipid Profile

Averaged Over Four Years

DSE

Mean

ILI

Mean

P-value

HDL (mgdl) 197 367 lt00001

TG (mgdl) -1975 -2556 00006

LDL (mgdl) -1284 -1127 0009

LDL (mgdl)

(Adjusting for

medication use)

-922 -875 042

Look AHEAD Research Group Arch Int Med 2010

Percent () Completing Outcome

Measures at Years 1-4

Intervention Group

(ILI)

Year 1 971

Year 2 949

Year 3 940

Year 4 941

Comparison Group

(DSE)

Year 1 957

Year 2 935

Year 3 938

Year 4 931

Look AHEAD Summary

ILI had significantly greater improvements than DSE in all CVD risk factors averaged across 4 years (except LDL-C)

There may be long-term beneficial effects from this 4-year period in which ILI subjects have been exposed to lower CVD risk factors

Longer follow-ups will determine whether these lowered CVD risk factors can be maintained amp whether lifestyle intervention has positive effects on CVD morbidity amp mortality

Mary J

Female

White

56 years old at start of Look AHEAD

study

Past Medical History Type 2 diabetes

overweight diverticulosis arthritis

sleep apnea back pain

Mary J

bullLong term strugglesbull Helping youngest daughter with

personal issues and children

bull Rotator cuff problems

bull Degenerative disks in back

bull Rheumatoid arthritis

bull Diabetes

bull Physically demanding job

bull Financial struggles

Pounds

Years

82007 grandkids enter pre-school

Catherine L

Female

White

47 years old at start of Look AHEAD

study

Past Medical History Type 2 diabetes

overweight high blood pressure

hypothyroidism back pain

Catherine L

Long term struggles

bull Motherrsquos declining health and death

bull Multiple serious injuries

bull Sudden death of sister

bull Death of step-father

bull Declining economy

bull Children living at home

Pounds

Years

Realistic Management Goals

5-10 weight loss

Health energy and fitness

Well-being and self-esteem

Mood and appearance

Functional and recreational

activity

Key Elements

Focus on health and energy

Food and physical activity diaries

Gradual increase in physical activity

Gradual reduction in dietary fat

No feelings of food deprivation

Social support groups

Recommended Strategies for Building

Sustainable Healthy Communities

Overview from USA

Promote the availability of affordable healthy

food and beverages

Support healthy food and beverage choices

Encourage breastfeeding

Encourage physical activity or limit sedentary

activity among children amp youth

Create safe communities that support physical

activity

Encourage communities to organize for change

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Increase the availability of healthier food and

beverage choices in public service venues (eg

schools city amp county buildings etc)

--Insufficient evidence in school-based programs

--Associations suggest availability amp increased

consumption

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve availability of affordable healthier

food amp beverage choices in public service

venues

--Reducing the cost of healthier foods

increases their purchase

--Providing coupons redeemable for

healthier foods increases their purchase

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve geographic availability of

supermarkets in underserved areas

-- Greater access to nearby supermarkets is

associated with healthier eating behaviors

-- Increasing the number of supermarkets in

underserved neighborhoods increased

real estate values increased economic

activity amp employment amp resulted in lower

food prices

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Provide incentives to food retailers to locate in

andor offer healthier food choices in

underserved areas

-- Presence of retail venues that provide healthier

foods is associated with better nutrition

-- Greater availability of supermarkets was

associated with lower adolescent BMI scores

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Improve availability of mechanisms for

purchasing foods from farms

--Evidence supporting a direct link between

purchasing food from farms amp improved diet is

limited

--Two studies of initiatives to encourage

participation in farmersrsquo market showed

increased intention to eat more fruits amp

vegetables but no direct evidence

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Provide incentives for the production

distribution and procurement of foods from local

farms

--No evidence has been published to link local

food production amp health outcomes

--There is a current study exploring the potential

nutritional amp health benefits of eating locally

grown foods

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Restrict availability of less healthy foods amp

beverages in public service venues

--No peer-reviewed studies examined the impact

designed to restrict availability of less healthy

foods in public service venues

--21 states have policies that restrict the sale of

competitive foods in schools beyond USDA

regulations however no studies have evaluated

the impact of the policies

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Institute smaller portion size options in public

service venues

--Evidence is lacking to demonstrate effectiveness

of population-based interventions aimed at

reducing portion sizes in public service venues

--Evidence from clinical studies in laboratories

demonstrates decreasing portion sizes

decreases energy intake

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Limit advertisements of less healthy foods amp

beverages

--Little evidence is available regarding the impact

of restricting advertising on purchasing amp

consumption of less healthy foods

--Cross-sectional time-series studies of tobacco-

control efforts suggest an association between

advertising bans amp decreased tobacco

consumption

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Discourage consumption of sugar-sweetened

beverages

--One longitudinal study of a school-based

intervention among Native-American high school

students showed a substantial reduction in

sugar-sweetened beverages over a 3-year

period

--A RCT of a home-based intervention that

eliminated sugar-sweetened beverages showed

reduction in BMI scores

Recommended Community Strategies Strategies to encourage breastfeeding

Increase support for breastfeeding

--Evidence directly linking environmental

interventions that support breastfeeding with

obesity-related outcomes is lacking

--Epidemiologic studies indicate that breastfeeding

helps prevent pediatric obesity

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Require physical education in schools

--14 studies have demonstrated that school-based

PE was effective in increasing levels of physical

activity and improving physical fitness

--Minimum of 150 minwk in elementary schools

225 minwk in middle schools and high schools

throughout the school year as recommended by

NASPE

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Increase opportunities for extracurricular

physical activity

--Participation in after-school programs increased

studentsrsquo level of physical activity amp improved

obesity-related outcomes (improved CV fitness

reduced body fat)

--2 pilot studies providing extracurricular physical

activity showed increased levels of PA amp

decreased sedentary behavior

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Reduce screen time in public service venues

--A school-based RCT indicated that children who

reduced their television videotape amp video

game use had significant decrease in BMI tricep

skin fold thickness amp waist circumference

compared to controls

--Spending less time watching television is

associated with increased physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Improve access to outdoor recreational

facilities

--Review of 108 studies indicated that access to facilities

and programs for recreation near their homes amp time

spent outdoors correlated positively with increased

physical activity among childrenamp adults

--Perceptions that footpaths are safe for walking was

significantly associated with adults being classified as

physically active at a level sufficient for health benefits

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting

bicycling

--Longitudinal intervention studies have

demonstrated that improving bicycling

infrastructure is associated with increased

frequency of bicycling

--Cross-sectional studies indicated a significant

association between bicycling infrastructure amp

frequency of biking

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting walking

--Reviews of cross-sectional studies of

environmental correlates of physical activity amp

walking generally find a positive association

between infrastructure supportive of walking amp

physical activity

--Identifying amp creating safe routes to school

together with educational components

increased the number of students walking to

school

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Locating schools within easy walking

distance of residential areas

--Community-scale urban design amp land use policies amp

practices including locating schools stores workplaces

amp recreation areas close to residential areas are

effective in facilitating an increase in levels of physical

activity

--Majority of efforts to encourage walking to school involve

improving the routes rather than improving the location

of schools

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Improve access to public transportation

--Insufficient evidence exists to determine

effectiveness of transportation policies in

increasing the level of physical activity or

improving fitness

--1 study indicated that 29 of individuals who

walk to and from public transit achieve at least

30 minutes of daily physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Zone for mixed-use development

--Allows residential commercial institutional amp

other public land uses to be located in close

proximity to one another

--Studies using correlation analyses amp regression

models indicated that mixed land use was

associated with increased walking amp cycling

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance personal safety in areas where

persons are or could be physically active

--Cross-sectional studies have demonstrated a

negative relationship between crime rates andor

perceived safety amp physical activity in

neighborhoods

--Few intervention studies have evaluated the

impact of policies amp practices to improve

personal safety on physical activity

Geospatial Mapping Linking Urban

Environments to Health Risk

Measure association between environmental variables amp health risk factors

Assess relationships between variables at different levels of analysis

Used in conjunction with linear analyses

Our Community Environmental Model

of Obesity

Community Factors

Poverty

Crime

Grocery Quality

Restaurants

Parks

Sidewalks

Fast Food Outlets

Recreational

Facilities

Individual Factors

Dietary Intake

Physical Activity

Genetics

Family History

StressCoping

Eating Disorders

Psychological

Problems

Weight

Status

Chosen Neighborhoods

Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped

We then matched census-block groups within the income groups by population density and percentage of minority representation

One matched block group per income level was randomly selected

Prevalence of Obesity in

Block-Groups

0

5

10

15

20

25

30

35

40

45

50

Ag

e-a

dju

sted

Ob

esit

y P

rev

ale

nce

(

)

High-Income Low-Income

Age-standardized to the 1990 US Census

Density of Environmental Factors in the

Community Contributes to a ldquoToxicrdquo

Obesity Environment

0

2

4

6

8

10

12

14

16

18

Fast-food Convenience Store Bars

Den

sity

10

00

perso

ns

High-Income Low-Income

COMMUNITYrsquoS PERCEPTION OF SAFETY

0

5

10

15

20

25

30

35

40

Daytime Nighttime

Perc

en

t (

) F

eeli

ng

So

mew

hat

Safe

or

Un

safe

Low-Income High-Income

Percent Substandard (or worse) Housing

or Ground Conditions

of Residential Properties

0

10

20

30

Structural Grounds

Perc

en

t (

)

Low-Income High-Income

CONCLUSIONS

These data suggest that the higher

frequency of outlets providing

calorically-dense foods and alcohol may

contribute to greater obesity prevalence

in residents of low-income communities

More research is needed to thoroughly

document environmental determinants

of health and obesity

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

From 1994-1998 HUD randomly assigned

4498 women with children living in public

housing in high-poverty urban census

tracts to one of three groups (1) housing

vouchers redeemable only if they moved

to a low-poverty census tract (2)

unrestricted vouchers or (3) control group

(no vouchers)

Ludwig et al NEJM 201136516

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

10-12 year follow-up showed modest but

potentially important reductions in the

prevalence of extreme obesity amp diabetes in the

group moving from a neighborhood with high

poverty on one of low poverty compared to the

control group

No differences between the group receiving

traditional vouchers amp the control group

ldquoNeighborhoods matterrdquo

Ludwig et al NEJM 201136516

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance traffic safety in areas where

persons are or could be physically active

--Community-scale urban design amp land use policies to

promote physical activity including design components

to improve street lighting infrastructure projects to

increase safety of pedestrian street crossing and use of

traffic calming approaches such as speed humps amp

traffic circles are effective in increasing physical activity

--Both community-scale amp street-scale policies amp practices

are effective in increasing physical activity

Recommended Community Strategies Encourage Communities to Organize for Change

Participate in community coalitions or

partnerships to address obesity

--Little evidence is available to determine the

impact of community coalitions on obesity

prevention

--The presence of anti-smoking community

coalitions has been associated with lower rates

of tobacco consumption

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

$103 million awarded to 61 states and

communities including state amp local government

agencies tribes amp territories amp state amp local non-

profit organizations

To build capacity to implement changes for

community prevention efforts to ensure long-

term success

To implement evidence-based and practice-

based programs to improve health amp wellness

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Priority areas are

Tobacco-free living

Active living and healthy eating

Evidence-based quality clinical and other

preventive health services for prevention

and control of high blood pressure and

high cholesterol

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Applicants proposed specific activities in

line with their chosen priority areas in their

applications

Grantee activities will not be finalized until

plans are negotiated with CDC by early

2012

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Capacity-Building Award

The Confederated Tribes of The Chehalis

Reservation is receiving a $498663 planning

award to build capacity to support healthy

lifestyles among their tribal population of 1500

in Washington State

Work will target tobacco-free living active living

and healthy eating and quality clinical and other

healthy serviceswwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Implementation Award

Austin TX Dept of Health and Human Services

is receiving $1026158 to serve Travis County

(Austin) to expand efforts in tobacco-free living

active living and healthy eating quality clinical

and other preventive services social and

emotional wellness and healthy and safe

physical environmentswwwcdcgov1052011

Building sustainable healthy

communities Bottom line

Obesity is an environmental problem

Despite progress in genetic research public health advances only will occur when we take the environment seriously

Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment

Until we do this we will not make substantial progress in addressing the epidemic of obesity

Poston amp Foreyt Atherosclerosis 1999

Whatrsquos the best approach

Integrate all sectors of society into community

change interventions

Incorporate

Science amp Technology

Education

FamilyCommunity

Healthcare

Arts amp Entertainment

Law amp Politics

Commerce amp Trade

Sectors of Society

Arts amp Entertainm

ent

Commerce amp Trade

Education

FamilyCommunity

Healthcare

Law amp Politics

Science amp Technology

Project FIT rationale design and baseline characteristics of a school- and community-

based intervention to address physical activity and healthy eating among low-income

elementary school children

Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D

Oh HJ Orth J Randall S Mayfield K Holmes D

Source

Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu

Abstract

BACKGROUND

This paper describes Project FIT a collaboration between the public school system local

health systems physicians neighborhood associations businesses faith-based leaders

community agencies and university researchers to develop a multi-faceted approach to

promote physical activity and healthy eating toward the general goal of preventing and

reducing childhood obesity among children in Grand Rapids MI USA

METHODSDESIGN

There are four overall components to Project FIT school community social marketing and

school staff wellness - all that focus on 1) increasing access to safe and affordable physical

activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)

improving the affordability and availability of nutritious food in the neighborhoods surrounding

the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding

nutrition and physical activity among school staff parents and students 4) impacting the

culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging

dialogue among all community partners to leverage existing programs and introduce new

ones

Most Promising Strategies For

Preventing Weight Regain

Extended treatments have shown

promise in promoting adherence to

the behaviors required for the long-

term maintenance of weight loss

Continuous care approach focused

on reasonable long-term objectives

appears appropriate for most

patients

Perri Foreyt amp Anton Preventing Weight Regain After Weight

Loss 2008

An Example of a successful long-term

intervention

The Look AHEAD Study

Does Weight Loss Reduce

Cardiovascular Disease and Death in

Overweight Individuals with Diabetes

bull Action for HEAlth in Diabetes

bull Objective to examine in overweight

persons with Type 2 Diabetes the long-

term effects of an intensive lifestyle

intervention program compared to

diabetes education and support

bull 16 Centers

bull 5145 overweight volunteers with

diabetes

Look AHEAD

Look AHEAD

Primary End Point Composite

bull Cardiovascular death (including fatal

myocardial infarction and stroke)

bull Non-fatal myocardial infarction

bull Non-fatal stroke

Winston-Salem

Baltimore

Philadelphia

New York

Providence

Boston

Clinical Site Coordinating Center

Clinical Sites

Seattle

Los Angeles

San AntonioHouston

Baton Rouge

Minneapolis

Memphis

Birmingham

Pittsburgh

Denver

Phoenix

Look AHEADParticipants

101100Baseline weight (kg)

589586Age (years)

9496Attended 1 year exam

360359Baseline BMI

1514Insulin Users

3737Minority

6059Women

(N=2574)(N=2630)

DSELifestyle

p lt 0004

Look AHEAD

Study Interventions

bull Diabetes support and education - DSE (control group)

bull Lifestyle intervention ndash ILI (treatment group)

Look AHEAD

Lifestyle Intervention

Goals

bull 7 weight loss for the group (10

for individual)

bull 175 minutes of moderate intensity

activity

Look AHEAD

Lifestyle Intervention

bull Diet

ndash ADA NCEP (lt 30 fat lt 10 sat fat

gt15 protein)

ndash 1200-1500 (if weight lt250lbs)

ndash 1500-1800 (if weight gt250lbs)

ndash During first 4 weeks to 4 months portion

control (liquid meal replacements or

structured meal plan)

Look AHEAD

Lifestyle Intervention

bull Physical Activity

ndash unsupervised

ndash 175 minutes moderate intensityweek

ndash 5 daysweek

ndash walking

Weight Loss at 1-Year

-9

ILI 0

-1

-2

-3

-4

-5

-6

-7

-8

DSE

p lt 00001

W

eig

ht

Chan

ge

86

07

The Look AHEAD Research Group Diabetes Care 2007

Reduction in Initial Weight by Gender

N=872

N=1229N=1197

N=830

-12

-10

-8

-6

-4

-2

0

0 2 4 6 8 10 12

Months

R

ed

uctio

n in

In

itia

l W

eig

ht

Men

Women

Plt0001

The Look AHEAD Research Group Diabetes Care 2007

Fitness Change () at 1-Year

0

5

10

15

20

25

Mean

Fitness C

hange

Unadjusted

Plt0001Adjusted for 1 Year

Weight Change Plt0001

58

209

108

159

DSE ILI ILIDSE

The Look AHEAD Research Group Diabetes Care 2007

1-Year Changes in Markers of

Diabetes Control

Markers of Diabetes

Control ILI DSE P-value

Hemoglobin A1c () BL

Hemoglobin A1c () Y1

Y1 ndash Baseline

725

661

-064

729

715

-014

026

lt0001

lt0001

Fasting glucose (mgdl) BL

Fasting glucose (mgdl) Y1

Y1 ndash Baseline

1519

1304

-215

1536

1464

-72

021

lt0001

lt0001

Diabetes medications BL

Diabetes medications Y1

Y1 ndash Baseline

865

786

-78

865

887

22

093

lt0001

lt0001

1-Year Changes in Markers of

Blood Pressure ControlMarkers of Blood Pressure

Control ILI DSE P-value

Systolic BP (mmHg) BL

Systolic BP (mmHg) Y1

Y1 ndash Baseline

1282

1214

-68

1294

1266

-28

026

lt0001

lt0001

Diastolic BP (mmHg) BL

Diastolic BP (mmHg) Y1

Y1 ndash Baseline

699

670

-30

704

686

-18

011

lt0001

lt0001

Antihypertensive medications BL

Antihypertensive medications Y1

Y1 ndash Baseline

753

752

-01

737

759

22

023

054

002

1-Year Changes in Markers of Lipid

Control

Markers of Lipid Control ILI DSE P-value

LDL-cholesterol (mgdl) BL

LDL-cholesterol (mgdl) Y1

Y1 ndash Baseline

1122

1070

-52

1124

1067

-57

078

074

049

HDL-cholesterol (mgdl) BL

HDL-cholesterol (mgdl) Y1

Y1 ndash Baseline

435

469

34

436

449

14

080

lt0001

lt0001

Triglycerides (mgdl) BL

Triglycerides (mgdl) Y1

Y1 ndash Baseline

1828

1525

-303

1800

1654

-146

038

lt0001

lt0001

Lipid lowering medications BL

Lipid lowering medications Y1

Y1 ndash Baseline

494

530

37

484

578

94

052

lt0001

lt0001

1-Year Changes in Percent of Participants

Meeting ADA Goals

ADA Goal ILI DSE P-value

Hemoglobin A1c lt 7 BL

Hemoglobin A1c lt 7 Y1

Y1 ndash Baseline

463

727

264

454

508

54

050

lt0001

lt0001

Blood pressure lt 13080 mmHg BL

Blood pressure lt 13080 mmHg Y1

Y1 ndash Baseline

535

686

151

499

570

70

001

lt0001

lt0001

LDL-cholesterol lt 100 mgdl BL

LDL-cholesterol lt 100 mgdl Y1

Y1 ndash Baseline

371

438

67

369

449

80

087

045

034

All three goals BL

All three goals Y1

Y1 ndash Baseline

108

236

128

95

160

65

013

lt0001

lt0001

Mean Changes in Weight Fitness amp BP

Averaged Over Four Years

DSE

Mean

ILI

Mean

P-value

Weight Loss

( initial wt)

-088 -615 lt 00001

Fitness

( METS)

196 1274 lt00001

HbA1c -009 -036 lt 00001

SBP (mm Hg) -297 -533 lt 00001

DBP (mm Hg) -248 -292 0012

Look AHEAD Research Group Arch Int Med 2010

Mean Changes in Lipid Profile

Averaged Over Four Years

DSE

Mean

ILI

Mean

P-value

HDL (mgdl) 197 367 lt00001

TG (mgdl) -1975 -2556 00006

LDL (mgdl) -1284 -1127 0009

LDL (mgdl)

(Adjusting for

medication use)

-922 -875 042

Look AHEAD Research Group Arch Int Med 2010

Percent () Completing Outcome

Measures at Years 1-4

Intervention Group

(ILI)

Year 1 971

Year 2 949

Year 3 940

Year 4 941

Comparison Group

(DSE)

Year 1 957

Year 2 935

Year 3 938

Year 4 931

Look AHEAD Summary

ILI had significantly greater improvements than DSE in all CVD risk factors averaged across 4 years (except LDL-C)

There may be long-term beneficial effects from this 4-year period in which ILI subjects have been exposed to lower CVD risk factors

Longer follow-ups will determine whether these lowered CVD risk factors can be maintained amp whether lifestyle intervention has positive effects on CVD morbidity amp mortality

Mary J

Female

White

56 years old at start of Look AHEAD

study

Past Medical History Type 2 diabetes

overweight diverticulosis arthritis

sleep apnea back pain

Mary J

bullLong term strugglesbull Helping youngest daughter with

personal issues and children

bull Rotator cuff problems

bull Degenerative disks in back

bull Rheumatoid arthritis

bull Diabetes

bull Physically demanding job

bull Financial struggles

Pounds

Years

82007 grandkids enter pre-school

Catherine L

Female

White

47 years old at start of Look AHEAD

study

Past Medical History Type 2 diabetes

overweight high blood pressure

hypothyroidism back pain

Catherine L

Long term struggles

bull Motherrsquos declining health and death

bull Multiple serious injuries

bull Sudden death of sister

bull Death of step-father

bull Declining economy

bull Children living at home

Pounds

Years

Realistic Management Goals

5-10 weight loss

Health energy and fitness

Well-being and self-esteem

Mood and appearance

Functional and recreational

activity

Key Elements

Focus on health and energy

Food and physical activity diaries

Gradual increase in physical activity

Gradual reduction in dietary fat

No feelings of food deprivation

Social support groups

Recommended Strategies for Building

Sustainable Healthy Communities

Overview from USA

Promote the availability of affordable healthy

food and beverages

Support healthy food and beverage choices

Encourage breastfeeding

Encourage physical activity or limit sedentary

activity among children amp youth

Create safe communities that support physical

activity

Encourage communities to organize for change

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Increase the availability of healthier food and

beverage choices in public service venues (eg

schools city amp county buildings etc)

--Insufficient evidence in school-based programs

--Associations suggest availability amp increased

consumption

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve availability of affordable healthier

food amp beverage choices in public service

venues

--Reducing the cost of healthier foods

increases their purchase

--Providing coupons redeemable for

healthier foods increases their purchase

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve geographic availability of

supermarkets in underserved areas

-- Greater access to nearby supermarkets is

associated with healthier eating behaviors

-- Increasing the number of supermarkets in

underserved neighborhoods increased

real estate values increased economic

activity amp employment amp resulted in lower

food prices

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Provide incentives to food retailers to locate in

andor offer healthier food choices in

underserved areas

-- Presence of retail venues that provide healthier

foods is associated with better nutrition

-- Greater availability of supermarkets was

associated with lower adolescent BMI scores

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Improve availability of mechanisms for

purchasing foods from farms

--Evidence supporting a direct link between

purchasing food from farms amp improved diet is

limited

--Two studies of initiatives to encourage

participation in farmersrsquo market showed

increased intention to eat more fruits amp

vegetables but no direct evidence

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Provide incentives for the production

distribution and procurement of foods from local

farms

--No evidence has been published to link local

food production amp health outcomes

--There is a current study exploring the potential

nutritional amp health benefits of eating locally

grown foods

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Restrict availability of less healthy foods amp

beverages in public service venues

--No peer-reviewed studies examined the impact

designed to restrict availability of less healthy

foods in public service venues

--21 states have policies that restrict the sale of

competitive foods in schools beyond USDA

regulations however no studies have evaluated

the impact of the policies

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Institute smaller portion size options in public

service venues

--Evidence is lacking to demonstrate effectiveness

of population-based interventions aimed at

reducing portion sizes in public service venues

--Evidence from clinical studies in laboratories

demonstrates decreasing portion sizes

decreases energy intake

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Limit advertisements of less healthy foods amp

beverages

--Little evidence is available regarding the impact

of restricting advertising on purchasing amp

consumption of less healthy foods

--Cross-sectional time-series studies of tobacco-

control efforts suggest an association between

advertising bans amp decreased tobacco

consumption

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Discourage consumption of sugar-sweetened

beverages

--One longitudinal study of a school-based

intervention among Native-American high school

students showed a substantial reduction in

sugar-sweetened beverages over a 3-year

period

--A RCT of a home-based intervention that

eliminated sugar-sweetened beverages showed

reduction in BMI scores

Recommended Community Strategies Strategies to encourage breastfeeding

Increase support for breastfeeding

--Evidence directly linking environmental

interventions that support breastfeeding with

obesity-related outcomes is lacking

--Epidemiologic studies indicate that breastfeeding

helps prevent pediatric obesity

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Require physical education in schools

--14 studies have demonstrated that school-based

PE was effective in increasing levels of physical

activity and improving physical fitness

--Minimum of 150 minwk in elementary schools

225 minwk in middle schools and high schools

throughout the school year as recommended by

NASPE

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Increase opportunities for extracurricular

physical activity

--Participation in after-school programs increased

studentsrsquo level of physical activity amp improved

obesity-related outcomes (improved CV fitness

reduced body fat)

--2 pilot studies providing extracurricular physical

activity showed increased levels of PA amp

decreased sedentary behavior

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Reduce screen time in public service venues

--A school-based RCT indicated that children who

reduced their television videotape amp video

game use had significant decrease in BMI tricep

skin fold thickness amp waist circumference

compared to controls

--Spending less time watching television is

associated with increased physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Improve access to outdoor recreational

facilities

--Review of 108 studies indicated that access to facilities

and programs for recreation near their homes amp time

spent outdoors correlated positively with increased

physical activity among childrenamp adults

--Perceptions that footpaths are safe for walking was

significantly associated with adults being classified as

physically active at a level sufficient for health benefits

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting

bicycling

--Longitudinal intervention studies have

demonstrated that improving bicycling

infrastructure is associated with increased

frequency of bicycling

--Cross-sectional studies indicated a significant

association between bicycling infrastructure amp

frequency of biking

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting walking

--Reviews of cross-sectional studies of

environmental correlates of physical activity amp

walking generally find a positive association

between infrastructure supportive of walking amp

physical activity

--Identifying amp creating safe routes to school

together with educational components

increased the number of students walking to

school

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Locating schools within easy walking

distance of residential areas

--Community-scale urban design amp land use policies amp

practices including locating schools stores workplaces

amp recreation areas close to residential areas are

effective in facilitating an increase in levels of physical

activity

--Majority of efforts to encourage walking to school involve

improving the routes rather than improving the location

of schools

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Improve access to public transportation

--Insufficient evidence exists to determine

effectiveness of transportation policies in

increasing the level of physical activity or

improving fitness

--1 study indicated that 29 of individuals who

walk to and from public transit achieve at least

30 minutes of daily physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Zone for mixed-use development

--Allows residential commercial institutional amp

other public land uses to be located in close

proximity to one another

--Studies using correlation analyses amp regression

models indicated that mixed land use was

associated with increased walking amp cycling

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance personal safety in areas where

persons are or could be physically active

--Cross-sectional studies have demonstrated a

negative relationship between crime rates andor

perceived safety amp physical activity in

neighborhoods

--Few intervention studies have evaluated the

impact of policies amp practices to improve

personal safety on physical activity

Geospatial Mapping Linking Urban

Environments to Health Risk

Measure association between environmental variables amp health risk factors

Assess relationships between variables at different levels of analysis

Used in conjunction with linear analyses

Our Community Environmental Model

of Obesity

Community Factors

Poverty

Crime

Grocery Quality

Restaurants

Parks

Sidewalks

Fast Food Outlets

Recreational

Facilities

Individual Factors

Dietary Intake

Physical Activity

Genetics

Family History

StressCoping

Eating Disorders

Psychological

Problems

Weight

Status

Chosen Neighborhoods

Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped

We then matched census-block groups within the income groups by population density and percentage of minority representation

One matched block group per income level was randomly selected

Prevalence of Obesity in

Block-Groups

0

5

10

15

20

25

30

35

40

45

50

Ag

e-a

dju

sted

Ob

esit

y P

rev

ale

nce

(

)

High-Income Low-Income

Age-standardized to the 1990 US Census

Density of Environmental Factors in the

Community Contributes to a ldquoToxicrdquo

Obesity Environment

0

2

4

6

8

10

12

14

16

18

Fast-food Convenience Store Bars

Den

sity

10

00

perso

ns

High-Income Low-Income

COMMUNITYrsquoS PERCEPTION OF SAFETY

0

5

10

15

20

25

30

35

40

Daytime Nighttime

Perc

en

t (

) F

eeli

ng

So

mew

hat

Safe

or

Un

safe

Low-Income High-Income

Percent Substandard (or worse) Housing

or Ground Conditions

of Residential Properties

0

10

20

30

Structural Grounds

Perc

en

t (

)

Low-Income High-Income

CONCLUSIONS

These data suggest that the higher

frequency of outlets providing

calorically-dense foods and alcohol may

contribute to greater obesity prevalence

in residents of low-income communities

More research is needed to thoroughly

document environmental determinants

of health and obesity

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

From 1994-1998 HUD randomly assigned

4498 women with children living in public

housing in high-poverty urban census

tracts to one of three groups (1) housing

vouchers redeemable only if they moved

to a low-poverty census tract (2)

unrestricted vouchers or (3) control group

(no vouchers)

Ludwig et al NEJM 201136516

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

10-12 year follow-up showed modest but

potentially important reductions in the

prevalence of extreme obesity amp diabetes in the

group moving from a neighborhood with high

poverty on one of low poverty compared to the

control group

No differences between the group receiving

traditional vouchers amp the control group

ldquoNeighborhoods matterrdquo

Ludwig et al NEJM 201136516

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance traffic safety in areas where

persons are or could be physically active

--Community-scale urban design amp land use policies to

promote physical activity including design components

to improve street lighting infrastructure projects to

increase safety of pedestrian street crossing and use of

traffic calming approaches such as speed humps amp

traffic circles are effective in increasing physical activity

--Both community-scale amp street-scale policies amp practices

are effective in increasing physical activity

Recommended Community Strategies Encourage Communities to Organize for Change

Participate in community coalitions or

partnerships to address obesity

--Little evidence is available to determine the

impact of community coalitions on obesity

prevention

--The presence of anti-smoking community

coalitions has been associated with lower rates

of tobacco consumption

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

$103 million awarded to 61 states and

communities including state amp local government

agencies tribes amp territories amp state amp local non-

profit organizations

To build capacity to implement changes for

community prevention efforts to ensure long-

term success

To implement evidence-based and practice-

based programs to improve health amp wellness

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Priority areas are

Tobacco-free living

Active living and healthy eating

Evidence-based quality clinical and other

preventive health services for prevention

and control of high blood pressure and

high cholesterol

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Applicants proposed specific activities in

line with their chosen priority areas in their

applications

Grantee activities will not be finalized until

plans are negotiated with CDC by early

2012

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Capacity-Building Award

The Confederated Tribes of The Chehalis

Reservation is receiving a $498663 planning

award to build capacity to support healthy

lifestyles among their tribal population of 1500

in Washington State

Work will target tobacco-free living active living

and healthy eating and quality clinical and other

healthy serviceswwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Implementation Award

Austin TX Dept of Health and Human Services

is receiving $1026158 to serve Travis County

(Austin) to expand efforts in tobacco-free living

active living and healthy eating quality clinical

and other preventive services social and

emotional wellness and healthy and safe

physical environmentswwwcdcgov1052011

Building sustainable healthy

communities Bottom line

Obesity is an environmental problem

Despite progress in genetic research public health advances only will occur when we take the environment seriously

Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment

Until we do this we will not make substantial progress in addressing the epidemic of obesity

Poston amp Foreyt Atherosclerosis 1999

Whatrsquos the best approach

Integrate all sectors of society into community

change interventions

Incorporate

Science amp Technology

Education

FamilyCommunity

Healthcare

Arts amp Entertainment

Law amp Politics

Commerce amp Trade

Sectors of Society

Arts amp Entertainm

ent

Commerce amp Trade

Education

FamilyCommunity

Healthcare

Law amp Politics

Science amp Technology

Project FIT rationale design and baseline characteristics of a school- and community-

based intervention to address physical activity and healthy eating among low-income

elementary school children

Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D

Oh HJ Orth J Randall S Mayfield K Holmes D

Source

Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu

Abstract

BACKGROUND

This paper describes Project FIT a collaboration between the public school system local

health systems physicians neighborhood associations businesses faith-based leaders

community agencies and university researchers to develop a multi-faceted approach to

promote physical activity and healthy eating toward the general goal of preventing and

reducing childhood obesity among children in Grand Rapids MI USA

METHODSDESIGN

There are four overall components to Project FIT school community social marketing and

school staff wellness - all that focus on 1) increasing access to safe and affordable physical

activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)

improving the affordability and availability of nutritious food in the neighborhoods surrounding

the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding

nutrition and physical activity among school staff parents and students 4) impacting the

culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging

dialogue among all community partners to leverage existing programs and introduce new

ones

An Example of a successful long-term

intervention

The Look AHEAD Study

Does Weight Loss Reduce

Cardiovascular Disease and Death in

Overweight Individuals with Diabetes

bull Action for HEAlth in Diabetes

bull Objective to examine in overweight

persons with Type 2 Diabetes the long-

term effects of an intensive lifestyle

intervention program compared to

diabetes education and support

bull 16 Centers

bull 5145 overweight volunteers with

diabetes

Look AHEAD

Look AHEAD

Primary End Point Composite

bull Cardiovascular death (including fatal

myocardial infarction and stroke)

bull Non-fatal myocardial infarction

bull Non-fatal stroke

Winston-Salem

Baltimore

Philadelphia

New York

Providence

Boston

Clinical Site Coordinating Center

Clinical Sites

Seattle

Los Angeles

San AntonioHouston

Baton Rouge

Minneapolis

Memphis

Birmingham

Pittsburgh

Denver

Phoenix

Look AHEADParticipants

101100Baseline weight (kg)

589586Age (years)

9496Attended 1 year exam

360359Baseline BMI

1514Insulin Users

3737Minority

6059Women

(N=2574)(N=2630)

DSELifestyle

p lt 0004

Look AHEAD

Study Interventions

bull Diabetes support and education - DSE (control group)

bull Lifestyle intervention ndash ILI (treatment group)

Look AHEAD

Lifestyle Intervention

Goals

bull 7 weight loss for the group (10

for individual)

bull 175 minutes of moderate intensity

activity

Look AHEAD

Lifestyle Intervention

bull Diet

ndash ADA NCEP (lt 30 fat lt 10 sat fat

gt15 protein)

ndash 1200-1500 (if weight lt250lbs)

ndash 1500-1800 (if weight gt250lbs)

ndash During first 4 weeks to 4 months portion

control (liquid meal replacements or

structured meal plan)

Look AHEAD

Lifestyle Intervention

bull Physical Activity

ndash unsupervised

ndash 175 minutes moderate intensityweek

ndash 5 daysweek

ndash walking

Weight Loss at 1-Year

-9

ILI 0

-1

-2

-3

-4

-5

-6

-7

-8

DSE

p lt 00001

W

eig

ht

Chan

ge

86

07

The Look AHEAD Research Group Diabetes Care 2007

Reduction in Initial Weight by Gender

N=872

N=1229N=1197

N=830

-12

-10

-8

-6

-4

-2

0

0 2 4 6 8 10 12

Months

R

ed

uctio

n in

In

itia

l W

eig

ht

Men

Women

Plt0001

The Look AHEAD Research Group Diabetes Care 2007

Fitness Change () at 1-Year

0

5

10

15

20

25

Mean

Fitness C

hange

Unadjusted

Plt0001Adjusted for 1 Year

Weight Change Plt0001

58

209

108

159

DSE ILI ILIDSE

The Look AHEAD Research Group Diabetes Care 2007

1-Year Changes in Markers of

Diabetes Control

Markers of Diabetes

Control ILI DSE P-value

Hemoglobin A1c () BL

Hemoglobin A1c () Y1

Y1 ndash Baseline

725

661

-064

729

715

-014

026

lt0001

lt0001

Fasting glucose (mgdl) BL

Fasting glucose (mgdl) Y1

Y1 ndash Baseline

1519

1304

-215

1536

1464

-72

021

lt0001

lt0001

Diabetes medications BL

Diabetes medications Y1

Y1 ndash Baseline

865

786

-78

865

887

22

093

lt0001

lt0001

1-Year Changes in Markers of

Blood Pressure ControlMarkers of Blood Pressure

Control ILI DSE P-value

Systolic BP (mmHg) BL

Systolic BP (mmHg) Y1

Y1 ndash Baseline

1282

1214

-68

1294

1266

-28

026

lt0001

lt0001

Diastolic BP (mmHg) BL

Diastolic BP (mmHg) Y1

Y1 ndash Baseline

699

670

-30

704

686

-18

011

lt0001

lt0001

Antihypertensive medications BL

Antihypertensive medications Y1

Y1 ndash Baseline

753

752

-01

737

759

22

023

054

002

1-Year Changes in Markers of Lipid

Control

Markers of Lipid Control ILI DSE P-value

LDL-cholesterol (mgdl) BL

LDL-cholesterol (mgdl) Y1

Y1 ndash Baseline

1122

1070

-52

1124

1067

-57

078

074

049

HDL-cholesterol (mgdl) BL

HDL-cholesterol (mgdl) Y1

Y1 ndash Baseline

435

469

34

436

449

14

080

lt0001

lt0001

Triglycerides (mgdl) BL

Triglycerides (mgdl) Y1

Y1 ndash Baseline

1828

1525

-303

1800

1654

-146

038

lt0001

lt0001

Lipid lowering medications BL

Lipid lowering medications Y1

Y1 ndash Baseline

494

530

37

484

578

94

052

lt0001

lt0001

1-Year Changes in Percent of Participants

Meeting ADA Goals

ADA Goal ILI DSE P-value

Hemoglobin A1c lt 7 BL

Hemoglobin A1c lt 7 Y1

Y1 ndash Baseline

463

727

264

454

508

54

050

lt0001

lt0001

Blood pressure lt 13080 mmHg BL

Blood pressure lt 13080 mmHg Y1

Y1 ndash Baseline

535

686

151

499

570

70

001

lt0001

lt0001

LDL-cholesterol lt 100 mgdl BL

LDL-cholesterol lt 100 mgdl Y1

Y1 ndash Baseline

371

438

67

369

449

80

087

045

034

All three goals BL

All three goals Y1

Y1 ndash Baseline

108

236

128

95

160

65

013

lt0001

lt0001

Mean Changes in Weight Fitness amp BP

Averaged Over Four Years

DSE

Mean

ILI

Mean

P-value

Weight Loss

( initial wt)

-088 -615 lt 00001

Fitness

( METS)

196 1274 lt00001

HbA1c -009 -036 lt 00001

SBP (mm Hg) -297 -533 lt 00001

DBP (mm Hg) -248 -292 0012

Look AHEAD Research Group Arch Int Med 2010

Mean Changes in Lipid Profile

Averaged Over Four Years

DSE

Mean

ILI

Mean

P-value

HDL (mgdl) 197 367 lt00001

TG (mgdl) -1975 -2556 00006

LDL (mgdl) -1284 -1127 0009

LDL (mgdl)

(Adjusting for

medication use)

-922 -875 042

Look AHEAD Research Group Arch Int Med 2010

Percent () Completing Outcome

Measures at Years 1-4

Intervention Group

(ILI)

Year 1 971

Year 2 949

Year 3 940

Year 4 941

Comparison Group

(DSE)

Year 1 957

Year 2 935

Year 3 938

Year 4 931

Look AHEAD Summary

ILI had significantly greater improvements than DSE in all CVD risk factors averaged across 4 years (except LDL-C)

There may be long-term beneficial effects from this 4-year period in which ILI subjects have been exposed to lower CVD risk factors

Longer follow-ups will determine whether these lowered CVD risk factors can be maintained amp whether lifestyle intervention has positive effects on CVD morbidity amp mortality

Mary J

Female

White

56 years old at start of Look AHEAD

study

Past Medical History Type 2 diabetes

overweight diverticulosis arthritis

sleep apnea back pain

Mary J

bullLong term strugglesbull Helping youngest daughter with

personal issues and children

bull Rotator cuff problems

bull Degenerative disks in back

bull Rheumatoid arthritis

bull Diabetes

bull Physically demanding job

bull Financial struggles

Pounds

Years

82007 grandkids enter pre-school

Catherine L

Female

White

47 years old at start of Look AHEAD

study

Past Medical History Type 2 diabetes

overweight high blood pressure

hypothyroidism back pain

Catherine L

Long term struggles

bull Motherrsquos declining health and death

bull Multiple serious injuries

bull Sudden death of sister

bull Death of step-father

bull Declining economy

bull Children living at home

Pounds

Years

Realistic Management Goals

5-10 weight loss

Health energy and fitness

Well-being and self-esteem

Mood and appearance

Functional and recreational

activity

Key Elements

Focus on health and energy

Food and physical activity diaries

Gradual increase in physical activity

Gradual reduction in dietary fat

No feelings of food deprivation

Social support groups

Recommended Strategies for Building

Sustainable Healthy Communities

Overview from USA

Promote the availability of affordable healthy

food and beverages

Support healthy food and beverage choices

Encourage breastfeeding

Encourage physical activity or limit sedentary

activity among children amp youth

Create safe communities that support physical

activity

Encourage communities to organize for change

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Increase the availability of healthier food and

beverage choices in public service venues (eg

schools city amp county buildings etc)

--Insufficient evidence in school-based programs

--Associations suggest availability amp increased

consumption

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve availability of affordable healthier

food amp beverage choices in public service

venues

--Reducing the cost of healthier foods

increases their purchase

--Providing coupons redeemable for

healthier foods increases their purchase

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve geographic availability of

supermarkets in underserved areas

-- Greater access to nearby supermarkets is

associated with healthier eating behaviors

-- Increasing the number of supermarkets in

underserved neighborhoods increased

real estate values increased economic

activity amp employment amp resulted in lower

food prices

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Provide incentives to food retailers to locate in

andor offer healthier food choices in

underserved areas

-- Presence of retail venues that provide healthier

foods is associated with better nutrition

-- Greater availability of supermarkets was

associated with lower adolescent BMI scores

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Improve availability of mechanisms for

purchasing foods from farms

--Evidence supporting a direct link between

purchasing food from farms amp improved diet is

limited

--Two studies of initiatives to encourage

participation in farmersrsquo market showed

increased intention to eat more fruits amp

vegetables but no direct evidence

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Provide incentives for the production

distribution and procurement of foods from local

farms

--No evidence has been published to link local

food production amp health outcomes

--There is a current study exploring the potential

nutritional amp health benefits of eating locally

grown foods

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Restrict availability of less healthy foods amp

beverages in public service venues

--No peer-reviewed studies examined the impact

designed to restrict availability of less healthy

foods in public service venues

--21 states have policies that restrict the sale of

competitive foods in schools beyond USDA

regulations however no studies have evaluated

the impact of the policies

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Institute smaller portion size options in public

service venues

--Evidence is lacking to demonstrate effectiveness

of population-based interventions aimed at

reducing portion sizes in public service venues

--Evidence from clinical studies in laboratories

demonstrates decreasing portion sizes

decreases energy intake

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Limit advertisements of less healthy foods amp

beverages

--Little evidence is available regarding the impact

of restricting advertising on purchasing amp

consumption of less healthy foods

--Cross-sectional time-series studies of tobacco-

control efforts suggest an association between

advertising bans amp decreased tobacco

consumption

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Discourage consumption of sugar-sweetened

beverages

--One longitudinal study of a school-based

intervention among Native-American high school

students showed a substantial reduction in

sugar-sweetened beverages over a 3-year

period

--A RCT of a home-based intervention that

eliminated sugar-sweetened beverages showed

reduction in BMI scores

Recommended Community Strategies Strategies to encourage breastfeeding

Increase support for breastfeeding

--Evidence directly linking environmental

interventions that support breastfeeding with

obesity-related outcomes is lacking

--Epidemiologic studies indicate that breastfeeding

helps prevent pediatric obesity

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Require physical education in schools

--14 studies have demonstrated that school-based

PE was effective in increasing levels of physical

activity and improving physical fitness

--Minimum of 150 minwk in elementary schools

225 minwk in middle schools and high schools

throughout the school year as recommended by

NASPE

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Increase opportunities for extracurricular

physical activity

--Participation in after-school programs increased

studentsrsquo level of physical activity amp improved

obesity-related outcomes (improved CV fitness

reduced body fat)

--2 pilot studies providing extracurricular physical

activity showed increased levels of PA amp

decreased sedentary behavior

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Reduce screen time in public service venues

--A school-based RCT indicated that children who

reduced their television videotape amp video

game use had significant decrease in BMI tricep

skin fold thickness amp waist circumference

compared to controls

--Spending less time watching television is

associated with increased physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Improve access to outdoor recreational

facilities

--Review of 108 studies indicated that access to facilities

and programs for recreation near their homes amp time

spent outdoors correlated positively with increased

physical activity among childrenamp adults

--Perceptions that footpaths are safe for walking was

significantly associated with adults being classified as

physically active at a level sufficient for health benefits

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting

bicycling

--Longitudinal intervention studies have

demonstrated that improving bicycling

infrastructure is associated with increased

frequency of bicycling

--Cross-sectional studies indicated a significant

association between bicycling infrastructure amp

frequency of biking

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting walking

--Reviews of cross-sectional studies of

environmental correlates of physical activity amp

walking generally find a positive association

between infrastructure supportive of walking amp

physical activity

--Identifying amp creating safe routes to school

together with educational components

increased the number of students walking to

school

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Locating schools within easy walking

distance of residential areas

--Community-scale urban design amp land use policies amp

practices including locating schools stores workplaces

amp recreation areas close to residential areas are

effective in facilitating an increase in levels of physical

activity

--Majority of efforts to encourage walking to school involve

improving the routes rather than improving the location

of schools

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Improve access to public transportation

--Insufficient evidence exists to determine

effectiveness of transportation policies in

increasing the level of physical activity or

improving fitness

--1 study indicated that 29 of individuals who

walk to and from public transit achieve at least

30 minutes of daily physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Zone for mixed-use development

--Allows residential commercial institutional amp

other public land uses to be located in close

proximity to one another

--Studies using correlation analyses amp regression

models indicated that mixed land use was

associated with increased walking amp cycling

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance personal safety in areas where

persons are or could be physically active

--Cross-sectional studies have demonstrated a

negative relationship between crime rates andor

perceived safety amp physical activity in

neighborhoods

--Few intervention studies have evaluated the

impact of policies amp practices to improve

personal safety on physical activity

Geospatial Mapping Linking Urban

Environments to Health Risk

Measure association between environmental variables amp health risk factors

Assess relationships between variables at different levels of analysis

Used in conjunction with linear analyses

Our Community Environmental Model

of Obesity

Community Factors

Poverty

Crime

Grocery Quality

Restaurants

Parks

Sidewalks

Fast Food Outlets

Recreational

Facilities

Individual Factors

Dietary Intake

Physical Activity

Genetics

Family History

StressCoping

Eating Disorders

Psychological

Problems

Weight

Status

Chosen Neighborhoods

Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped

We then matched census-block groups within the income groups by population density and percentage of minority representation

One matched block group per income level was randomly selected

Prevalence of Obesity in

Block-Groups

0

5

10

15

20

25

30

35

40

45

50

Ag

e-a

dju

sted

Ob

esit

y P

rev

ale

nce

(

)

High-Income Low-Income

Age-standardized to the 1990 US Census

Density of Environmental Factors in the

Community Contributes to a ldquoToxicrdquo

Obesity Environment

0

2

4

6

8

10

12

14

16

18

Fast-food Convenience Store Bars

Den

sity

10

00

perso

ns

High-Income Low-Income

COMMUNITYrsquoS PERCEPTION OF SAFETY

0

5

10

15

20

25

30

35

40

Daytime Nighttime

Perc

en

t (

) F

eeli

ng

So

mew

hat

Safe

or

Un

safe

Low-Income High-Income

Percent Substandard (or worse) Housing

or Ground Conditions

of Residential Properties

0

10

20

30

Structural Grounds

Perc

en

t (

)

Low-Income High-Income

CONCLUSIONS

These data suggest that the higher

frequency of outlets providing

calorically-dense foods and alcohol may

contribute to greater obesity prevalence

in residents of low-income communities

More research is needed to thoroughly

document environmental determinants

of health and obesity

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

From 1994-1998 HUD randomly assigned

4498 women with children living in public

housing in high-poverty urban census

tracts to one of three groups (1) housing

vouchers redeemable only if they moved

to a low-poverty census tract (2)

unrestricted vouchers or (3) control group

(no vouchers)

Ludwig et al NEJM 201136516

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

10-12 year follow-up showed modest but

potentially important reductions in the

prevalence of extreme obesity amp diabetes in the

group moving from a neighborhood with high

poverty on one of low poverty compared to the

control group

No differences between the group receiving

traditional vouchers amp the control group

ldquoNeighborhoods matterrdquo

Ludwig et al NEJM 201136516

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance traffic safety in areas where

persons are or could be physically active

--Community-scale urban design amp land use policies to

promote physical activity including design components

to improve street lighting infrastructure projects to

increase safety of pedestrian street crossing and use of

traffic calming approaches such as speed humps amp

traffic circles are effective in increasing physical activity

--Both community-scale amp street-scale policies amp practices

are effective in increasing physical activity

Recommended Community Strategies Encourage Communities to Organize for Change

Participate in community coalitions or

partnerships to address obesity

--Little evidence is available to determine the

impact of community coalitions on obesity

prevention

--The presence of anti-smoking community

coalitions has been associated with lower rates

of tobacco consumption

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

$103 million awarded to 61 states and

communities including state amp local government

agencies tribes amp territories amp state amp local non-

profit organizations

To build capacity to implement changes for

community prevention efforts to ensure long-

term success

To implement evidence-based and practice-

based programs to improve health amp wellness

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Priority areas are

Tobacco-free living

Active living and healthy eating

Evidence-based quality clinical and other

preventive health services for prevention

and control of high blood pressure and

high cholesterol

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Applicants proposed specific activities in

line with their chosen priority areas in their

applications

Grantee activities will not be finalized until

plans are negotiated with CDC by early

2012

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Capacity-Building Award

The Confederated Tribes of The Chehalis

Reservation is receiving a $498663 planning

award to build capacity to support healthy

lifestyles among their tribal population of 1500

in Washington State

Work will target tobacco-free living active living

and healthy eating and quality clinical and other

healthy serviceswwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Implementation Award

Austin TX Dept of Health and Human Services

is receiving $1026158 to serve Travis County

(Austin) to expand efforts in tobacco-free living

active living and healthy eating quality clinical

and other preventive services social and

emotional wellness and healthy and safe

physical environmentswwwcdcgov1052011

Building sustainable healthy

communities Bottom line

Obesity is an environmental problem

Despite progress in genetic research public health advances only will occur when we take the environment seriously

Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment

Until we do this we will not make substantial progress in addressing the epidemic of obesity

Poston amp Foreyt Atherosclerosis 1999

Whatrsquos the best approach

Integrate all sectors of society into community

change interventions

Incorporate

Science amp Technology

Education

FamilyCommunity

Healthcare

Arts amp Entertainment

Law amp Politics

Commerce amp Trade

Sectors of Society

Arts amp Entertainm

ent

Commerce amp Trade

Education

FamilyCommunity

Healthcare

Law amp Politics

Science amp Technology

Project FIT rationale design and baseline characteristics of a school- and community-

based intervention to address physical activity and healthy eating among low-income

elementary school children

Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D

Oh HJ Orth J Randall S Mayfield K Holmes D

Source

Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu

Abstract

BACKGROUND

This paper describes Project FIT a collaboration between the public school system local

health systems physicians neighborhood associations businesses faith-based leaders

community agencies and university researchers to develop a multi-faceted approach to

promote physical activity and healthy eating toward the general goal of preventing and

reducing childhood obesity among children in Grand Rapids MI USA

METHODSDESIGN

There are four overall components to Project FIT school community social marketing and

school staff wellness - all that focus on 1) increasing access to safe and affordable physical

activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)

improving the affordability and availability of nutritious food in the neighborhoods surrounding

the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding

nutrition and physical activity among school staff parents and students 4) impacting the

culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging

dialogue among all community partners to leverage existing programs and introduce new

ones

bull Action for HEAlth in Diabetes

bull Objective to examine in overweight

persons with Type 2 Diabetes the long-

term effects of an intensive lifestyle

intervention program compared to

diabetes education and support

bull 16 Centers

bull 5145 overweight volunteers with

diabetes

Look AHEAD

Look AHEAD

Primary End Point Composite

bull Cardiovascular death (including fatal

myocardial infarction and stroke)

bull Non-fatal myocardial infarction

bull Non-fatal stroke

Winston-Salem

Baltimore

Philadelphia

New York

Providence

Boston

Clinical Site Coordinating Center

Clinical Sites

Seattle

Los Angeles

San AntonioHouston

Baton Rouge

Minneapolis

Memphis

Birmingham

Pittsburgh

Denver

Phoenix

Look AHEADParticipants

101100Baseline weight (kg)

589586Age (years)

9496Attended 1 year exam

360359Baseline BMI

1514Insulin Users

3737Minority

6059Women

(N=2574)(N=2630)

DSELifestyle

p lt 0004

Look AHEAD

Study Interventions

bull Diabetes support and education - DSE (control group)

bull Lifestyle intervention ndash ILI (treatment group)

Look AHEAD

Lifestyle Intervention

Goals

bull 7 weight loss for the group (10

for individual)

bull 175 minutes of moderate intensity

activity

Look AHEAD

Lifestyle Intervention

bull Diet

ndash ADA NCEP (lt 30 fat lt 10 sat fat

gt15 protein)

ndash 1200-1500 (if weight lt250lbs)

ndash 1500-1800 (if weight gt250lbs)

ndash During first 4 weeks to 4 months portion

control (liquid meal replacements or

structured meal plan)

Look AHEAD

Lifestyle Intervention

bull Physical Activity

ndash unsupervised

ndash 175 minutes moderate intensityweek

ndash 5 daysweek

ndash walking

Weight Loss at 1-Year

-9

ILI 0

-1

-2

-3

-4

-5

-6

-7

-8

DSE

p lt 00001

W

eig

ht

Chan

ge

86

07

The Look AHEAD Research Group Diabetes Care 2007

Reduction in Initial Weight by Gender

N=872

N=1229N=1197

N=830

-12

-10

-8

-6

-4

-2

0

0 2 4 6 8 10 12

Months

R

ed

uctio

n in

In

itia

l W

eig

ht

Men

Women

Plt0001

The Look AHEAD Research Group Diabetes Care 2007

Fitness Change () at 1-Year

0

5

10

15

20

25

Mean

Fitness C

hange

Unadjusted

Plt0001Adjusted for 1 Year

Weight Change Plt0001

58

209

108

159

DSE ILI ILIDSE

The Look AHEAD Research Group Diabetes Care 2007

1-Year Changes in Markers of

Diabetes Control

Markers of Diabetes

Control ILI DSE P-value

Hemoglobin A1c () BL

Hemoglobin A1c () Y1

Y1 ndash Baseline

725

661

-064

729

715

-014

026

lt0001

lt0001

Fasting glucose (mgdl) BL

Fasting glucose (mgdl) Y1

Y1 ndash Baseline

1519

1304

-215

1536

1464

-72

021

lt0001

lt0001

Diabetes medications BL

Diabetes medications Y1

Y1 ndash Baseline

865

786

-78

865

887

22

093

lt0001

lt0001

1-Year Changes in Markers of

Blood Pressure ControlMarkers of Blood Pressure

Control ILI DSE P-value

Systolic BP (mmHg) BL

Systolic BP (mmHg) Y1

Y1 ndash Baseline

1282

1214

-68

1294

1266

-28

026

lt0001

lt0001

Diastolic BP (mmHg) BL

Diastolic BP (mmHg) Y1

Y1 ndash Baseline

699

670

-30

704

686

-18

011

lt0001

lt0001

Antihypertensive medications BL

Antihypertensive medications Y1

Y1 ndash Baseline

753

752

-01

737

759

22

023

054

002

1-Year Changes in Markers of Lipid

Control

Markers of Lipid Control ILI DSE P-value

LDL-cholesterol (mgdl) BL

LDL-cholesterol (mgdl) Y1

Y1 ndash Baseline

1122

1070

-52

1124

1067

-57

078

074

049

HDL-cholesterol (mgdl) BL

HDL-cholesterol (mgdl) Y1

Y1 ndash Baseline

435

469

34

436

449

14

080

lt0001

lt0001

Triglycerides (mgdl) BL

Triglycerides (mgdl) Y1

Y1 ndash Baseline

1828

1525

-303

1800

1654

-146

038

lt0001

lt0001

Lipid lowering medications BL

Lipid lowering medications Y1

Y1 ndash Baseline

494

530

37

484

578

94

052

lt0001

lt0001

1-Year Changes in Percent of Participants

Meeting ADA Goals

ADA Goal ILI DSE P-value

Hemoglobin A1c lt 7 BL

Hemoglobin A1c lt 7 Y1

Y1 ndash Baseline

463

727

264

454

508

54

050

lt0001

lt0001

Blood pressure lt 13080 mmHg BL

Blood pressure lt 13080 mmHg Y1

Y1 ndash Baseline

535

686

151

499

570

70

001

lt0001

lt0001

LDL-cholesterol lt 100 mgdl BL

LDL-cholesterol lt 100 mgdl Y1

Y1 ndash Baseline

371

438

67

369

449

80

087

045

034

All three goals BL

All three goals Y1

Y1 ndash Baseline

108

236

128

95

160

65

013

lt0001

lt0001

Mean Changes in Weight Fitness amp BP

Averaged Over Four Years

DSE

Mean

ILI

Mean

P-value

Weight Loss

( initial wt)

-088 -615 lt 00001

Fitness

( METS)

196 1274 lt00001

HbA1c -009 -036 lt 00001

SBP (mm Hg) -297 -533 lt 00001

DBP (mm Hg) -248 -292 0012

Look AHEAD Research Group Arch Int Med 2010

Mean Changes in Lipid Profile

Averaged Over Four Years

DSE

Mean

ILI

Mean

P-value

HDL (mgdl) 197 367 lt00001

TG (mgdl) -1975 -2556 00006

LDL (mgdl) -1284 -1127 0009

LDL (mgdl)

(Adjusting for

medication use)

-922 -875 042

Look AHEAD Research Group Arch Int Med 2010

Percent () Completing Outcome

Measures at Years 1-4

Intervention Group

(ILI)

Year 1 971

Year 2 949

Year 3 940

Year 4 941

Comparison Group

(DSE)

Year 1 957

Year 2 935

Year 3 938

Year 4 931

Look AHEAD Summary

ILI had significantly greater improvements than DSE in all CVD risk factors averaged across 4 years (except LDL-C)

There may be long-term beneficial effects from this 4-year period in which ILI subjects have been exposed to lower CVD risk factors

Longer follow-ups will determine whether these lowered CVD risk factors can be maintained amp whether lifestyle intervention has positive effects on CVD morbidity amp mortality

Mary J

Female

White

56 years old at start of Look AHEAD

study

Past Medical History Type 2 diabetes

overweight diverticulosis arthritis

sleep apnea back pain

Mary J

bullLong term strugglesbull Helping youngest daughter with

personal issues and children

bull Rotator cuff problems

bull Degenerative disks in back

bull Rheumatoid arthritis

bull Diabetes

bull Physically demanding job

bull Financial struggles

Pounds

Years

82007 grandkids enter pre-school

Catherine L

Female

White

47 years old at start of Look AHEAD

study

Past Medical History Type 2 diabetes

overweight high blood pressure

hypothyroidism back pain

Catherine L

Long term struggles

bull Motherrsquos declining health and death

bull Multiple serious injuries

bull Sudden death of sister

bull Death of step-father

bull Declining economy

bull Children living at home

Pounds

Years

Realistic Management Goals

5-10 weight loss

Health energy and fitness

Well-being and self-esteem

Mood and appearance

Functional and recreational

activity

Key Elements

Focus on health and energy

Food and physical activity diaries

Gradual increase in physical activity

Gradual reduction in dietary fat

No feelings of food deprivation

Social support groups

Recommended Strategies for Building

Sustainable Healthy Communities

Overview from USA

Promote the availability of affordable healthy

food and beverages

Support healthy food and beverage choices

Encourage breastfeeding

Encourage physical activity or limit sedentary

activity among children amp youth

Create safe communities that support physical

activity

Encourage communities to organize for change

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Increase the availability of healthier food and

beverage choices in public service venues (eg

schools city amp county buildings etc)

--Insufficient evidence in school-based programs

--Associations suggest availability amp increased

consumption

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve availability of affordable healthier

food amp beverage choices in public service

venues

--Reducing the cost of healthier foods

increases their purchase

--Providing coupons redeemable for

healthier foods increases their purchase

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve geographic availability of

supermarkets in underserved areas

-- Greater access to nearby supermarkets is

associated with healthier eating behaviors

-- Increasing the number of supermarkets in

underserved neighborhoods increased

real estate values increased economic

activity amp employment amp resulted in lower

food prices

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Provide incentives to food retailers to locate in

andor offer healthier food choices in

underserved areas

-- Presence of retail venues that provide healthier

foods is associated with better nutrition

-- Greater availability of supermarkets was

associated with lower adolescent BMI scores

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Improve availability of mechanisms for

purchasing foods from farms

--Evidence supporting a direct link between

purchasing food from farms amp improved diet is

limited

--Two studies of initiatives to encourage

participation in farmersrsquo market showed

increased intention to eat more fruits amp

vegetables but no direct evidence

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Provide incentives for the production

distribution and procurement of foods from local

farms

--No evidence has been published to link local

food production amp health outcomes

--There is a current study exploring the potential

nutritional amp health benefits of eating locally

grown foods

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Restrict availability of less healthy foods amp

beverages in public service venues

--No peer-reviewed studies examined the impact

designed to restrict availability of less healthy

foods in public service venues

--21 states have policies that restrict the sale of

competitive foods in schools beyond USDA

regulations however no studies have evaluated

the impact of the policies

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Institute smaller portion size options in public

service venues

--Evidence is lacking to demonstrate effectiveness

of population-based interventions aimed at

reducing portion sizes in public service venues

--Evidence from clinical studies in laboratories

demonstrates decreasing portion sizes

decreases energy intake

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Limit advertisements of less healthy foods amp

beverages

--Little evidence is available regarding the impact

of restricting advertising on purchasing amp

consumption of less healthy foods

--Cross-sectional time-series studies of tobacco-

control efforts suggest an association between

advertising bans amp decreased tobacco

consumption

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Discourage consumption of sugar-sweetened

beverages

--One longitudinal study of a school-based

intervention among Native-American high school

students showed a substantial reduction in

sugar-sweetened beverages over a 3-year

period

--A RCT of a home-based intervention that

eliminated sugar-sweetened beverages showed

reduction in BMI scores

Recommended Community Strategies Strategies to encourage breastfeeding

Increase support for breastfeeding

--Evidence directly linking environmental

interventions that support breastfeeding with

obesity-related outcomes is lacking

--Epidemiologic studies indicate that breastfeeding

helps prevent pediatric obesity

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Require physical education in schools

--14 studies have demonstrated that school-based

PE was effective in increasing levels of physical

activity and improving physical fitness

--Minimum of 150 minwk in elementary schools

225 minwk in middle schools and high schools

throughout the school year as recommended by

NASPE

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Increase opportunities for extracurricular

physical activity

--Participation in after-school programs increased

studentsrsquo level of physical activity amp improved

obesity-related outcomes (improved CV fitness

reduced body fat)

--2 pilot studies providing extracurricular physical

activity showed increased levels of PA amp

decreased sedentary behavior

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Reduce screen time in public service venues

--A school-based RCT indicated that children who

reduced their television videotape amp video

game use had significant decrease in BMI tricep

skin fold thickness amp waist circumference

compared to controls

--Spending less time watching television is

associated with increased physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Improve access to outdoor recreational

facilities

--Review of 108 studies indicated that access to facilities

and programs for recreation near their homes amp time

spent outdoors correlated positively with increased

physical activity among childrenamp adults

--Perceptions that footpaths are safe for walking was

significantly associated with adults being classified as

physically active at a level sufficient for health benefits

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting

bicycling

--Longitudinal intervention studies have

demonstrated that improving bicycling

infrastructure is associated with increased

frequency of bicycling

--Cross-sectional studies indicated a significant

association between bicycling infrastructure amp

frequency of biking

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting walking

--Reviews of cross-sectional studies of

environmental correlates of physical activity amp

walking generally find a positive association

between infrastructure supportive of walking amp

physical activity

--Identifying amp creating safe routes to school

together with educational components

increased the number of students walking to

school

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Locating schools within easy walking

distance of residential areas

--Community-scale urban design amp land use policies amp

practices including locating schools stores workplaces

amp recreation areas close to residential areas are

effective in facilitating an increase in levels of physical

activity

--Majority of efforts to encourage walking to school involve

improving the routes rather than improving the location

of schools

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Improve access to public transportation

--Insufficient evidence exists to determine

effectiveness of transportation policies in

increasing the level of physical activity or

improving fitness

--1 study indicated that 29 of individuals who

walk to and from public transit achieve at least

30 minutes of daily physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Zone for mixed-use development

--Allows residential commercial institutional amp

other public land uses to be located in close

proximity to one another

--Studies using correlation analyses amp regression

models indicated that mixed land use was

associated with increased walking amp cycling

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance personal safety in areas where

persons are or could be physically active

--Cross-sectional studies have demonstrated a

negative relationship between crime rates andor

perceived safety amp physical activity in

neighborhoods

--Few intervention studies have evaluated the

impact of policies amp practices to improve

personal safety on physical activity

Geospatial Mapping Linking Urban

Environments to Health Risk

Measure association between environmental variables amp health risk factors

Assess relationships between variables at different levels of analysis

Used in conjunction with linear analyses

Our Community Environmental Model

of Obesity

Community Factors

Poverty

Crime

Grocery Quality

Restaurants

Parks

Sidewalks

Fast Food Outlets

Recreational

Facilities

Individual Factors

Dietary Intake

Physical Activity

Genetics

Family History

StressCoping

Eating Disorders

Psychological

Problems

Weight

Status

Chosen Neighborhoods

Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped

We then matched census-block groups within the income groups by population density and percentage of minority representation

One matched block group per income level was randomly selected

Prevalence of Obesity in

Block-Groups

0

5

10

15

20

25

30

35

40

45

50

Ag

e-a

dju

sted

Ob

esit

y P

rev

ale

nce

(

)

High-Income Low-Income

Age-standardized to the 1990 US Census

Density of Environmental Factors in the

Community Contributes to a ldquoToxicrdquo

Obesity Environment

0

2

4

6

8

10

12

14

16

18

Fast-food Convenience Store Bars

Den

sity

10

00

perso

ns

High-Income Low-Income

COMMUNITYrsquoS PERCEPTION OF SAFETY

0

5

10

15

20

25

30

35

40

Daytime Nighttime

Perc

en

t (

) F

eeli

ng

So

mew

hat

Safe

or

Un

safe

Low-Income High-Income

Percent Substandard (or worse) Housing

or Ground Conditions

of Residential Properties

0

10

20

30

Structural Grounds

Perc

en

t (

)

Low-Income High-Income

CONCLUSIONS

These data suggest that the higher

frequency of outlets providing

calorically-dense foods and alcohol may

contribute to greater obesity prevalence

in residents of low-income communities

More research is needed to thoroughly

document environmental determinants

of health and obesity

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

From 1994-1998 HUD randomly assigned

4498 women with children living in public

housing in high-poverty urban census

tracts to one of three groups (1) housing

vouchers redeemable only if they moved

to a low-poverty census tract (2)

unrestricted vouchers or (3) control group

(no vouchers)

Ludwig et al NEJM 201136516

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

10-12 year follow-up showed modest but

potentially important reductions in the

prevalence of extreme obesity amp diabetes in the

group moving from a neighborhood with high

poverty on one of low poverty compared to the

control group

No differences between the group receiving

traditional vouchers amp the control group

ldquoNeighborhoods matterrdquo

Ludwig et al NEJM 201136516

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance traffic safety in areas where

persons are or could be physically active

--Community-scale urban design amp land use policies to

promote physical activity including design components

to improve street lighting infrastructure projects to

increase safety of pedestrian street crossing and use of

traffic calming approaches such as speed humps amp

traffic circles are effective in increasing physical activity

--Both community-scale amp street-scale policies amp practices

are effective in increasing physical activity

Recommended Community Strategies Encourage Communities to Organize for Change

Participate in community coalitions or

partnerships to address obesity

--Little evidence is available to determine the

impact of community coalitions on obesity

prevention

--The presence of anti-smoking community

coalitions has been associated with lower rates

of tobacco consumption

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

$103 million awarded to 61 states and

communities including state amp local government

agencies tribes amp territories amp state amp local non-

profit organizations

To build capacity to implement changes for

community prevention efforts to ensure long-

term success

To implement evidence-based and practice-

based programs to improve health amp wellness

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Priority areas are

Tobacco-free living

Active living and healthy eating

Evidence-based quality clinical and other

preventive health services for prevention

and control of high blood pressure and

high cholesterol

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Applicants proposed specific activities in

line with their chosen priority areas in their

applications

Grantee activities will not be finalized until

plans are negotiated with CDC by early

2012

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Capacity-Building Award

The Confederated Tribes of The Chehalis

Reservation is receiving a $498663 planning

award to build capacity to support healthy

lifestyles among their tribal population of 1500

in Washington State

Work will target tobacco-free living active living

and healthy eating and quality clinical and other

healthy serviceswwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Implementation Award

Austin TX Dept of Health and Human Services

is receiving $1026158 to serve Travis County

(Austin) to expand efforts in tobacco-free living

active living and healthy eating quality clinical

and other preventive services social and

emotional wellness and healthy and safe

physical environmentswwwcdcgov1052011

Building sustainable healthy

communities Bottom line

Obesity is an environmental problem

Despite progress in genetic research public health advances only will occur when we take the environment seriously

Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment

Until we do this we will not make substantial progress in addressing the epidemic of obesity

Poston amp Foreyt Atherosclerosis 1999

Whatrsquos the best approach

Integrate all sectors of society into community

change interventions

Incorporate

Science amp Technology

Education

FamilyCommunity

Healthcare

Arts amp Entertainment

Law amp Politics

Commerce amp Trade

Sectors of Society

Arts amp Entertainm

ent

Commerce amp Trade

Education

FamilyCommunity

Healthcare

Law amp Politics

Science amp Technology

Project FIT rationale design and baseline characteristics of a school- and community-

based intervention to address physical activity and healthy eating among low-income

elementary school children

Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D

Oh HJ Orth J Randall S Mayfield K Holmes D

Source

Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu

Abstract

BACKGROUND

This paper describes Project FIT a collaboration between the public school system local

health systems physicians neighborhood associations businesses faith-based leaders

community agencies and university researchers to develop a multi-faceted approach to

promote physical activity and healthy eating toward the general goal of preventing and

reducing childhood obesity among children in Grand Rapids MI USA

METHODSDESIGN

There are four overall components to Project FIT school community social marketing and

school staff wellness - all that focus on 1) increasing access to safe and affordable physical

activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)

improving the affordability and availability of nutritious food in the neighborhoods surrounding

the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding

nutrition and physical activity among school staff parents and students 4) impacting the

culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging

dialogue among all community partners to leverage existing programs and introduce new

ones

Look AHEAD

Primary End Point Composite

bull Cardiovascular death (including fatal

myocardial infarction and stroke)

bull Non-fatal myocardial infarction

bull Non-fatal stroke

Winston-Salem

Baltimore

Philadelphia

New York

Providence

Boston

Clinical Site Coordinating Center

Clinical Sites

Seattle

Los Angeles

San AntonioHouston

Baton Rouge

Minneapolis

Memphis

Birmingham

Pittsburgh

Denver

Phoenix

Look AHEADParticipants

101100Baseline weight (kg)

589586Age (years)

9496Attended 1 year exam

360359Baseline BMI

1514Insulin Users

3737Minority

6059Women

(N=2574)(N=2630)

DSELifestyle

p lt 0004

Look AHEAD

Study Interventions

bull Diabetes support and education - DSE (control group)

bull Lifestyle intervention ndash ILI (treatment group)

Look AHEAD

Lifestyle Intervention

Goals

bull 7 weight loss for the group (10

for individual)

bull 175 minutes of moderate intensity

activity

Look AHEAD

Lifestyle Intervention

bull Diet

ndash ADA NCEP (lt 30 fat lt 10 sat fat

gt15 protein)

ndash 1200-1500 (if weight lt250lbs)

ndash 1500-1800 (if weight gt250lbs)

ndash During first 4 weeks to 4 months portion

control (liquid meal replacements or

structured meal plan)

Look AHEAD

Lifestyle Intervention

bull Physical Activity

ndash unsupervised

ndash 175 minutes moderate intensityweek

ndash 5 daysweek

ndash walking

Weight Loss at 1-Year

-9

ILI 0

-1

-2

-3

-4

-5

-6

-7

-8

DSE

p lt 00001

W

eig

ht

Chan

ge

86

07

The Look AHEAD Research Group Diabetes Care 2007

Reduction in Initial Weight by Gender

N=872

N=1229N=1197

N=830

-12

-10

-8

-6

-4

-2

0

0 2 4 6 8 10 12

Months

R

ed

uctio

n in

In

itia

l W

eig

ht

Men

Women

Plt0001

The Look AHEAD Research Group Diabetes Care 2007

Fitness Change () at 1-Year

0

5

10

15

20

25

Mean

Fitness C

hange

Unadjusted

Plt0001Adjusted for 1 Year

Weight Change Plt0001

58

209

108

159

DSE ILI ILIDSE

The Look AHEAD Research Group Diabetes Care 2007

1-Year Changes in Markers of

Diabetes Control

Markers of Diabetes

Control ILI DSE P-value

Hemoglobin A1c () BL

Hemoglobin A1c () Y1

Y1 ndash Baseline

725

661

-064

729

715

-014

026

lt0001

lt0001

Fasting glucose (mgdl) BL

Fasting glucose (mgdl) Y1

Y1 ndash Baseline

1519

1304

-215

1536

1464

-72

021

lt0001

lt0001

Diabetes medications BL

Diabetes medications Y1

Y1 ndash Baseline

865

786

-78

865

887

22

093

lt0001

lt0001

1-Year Changes in Markers of

Blood Pressure ControlMarkers of Blood Pressure

Control ILI DSE P-value

Systolic BP (mmHg) BL

Systolic BP (mmHg) Y1

Y1 ndash Baseline

1282

1214

-68

1294

1266

-28

026

lt0001

lt0001

Diastolic BP (mmHg) BL

Diastolic BP (mmHg) Y1

Y1 ndash Baseline

699

670

-30

704

686

-18

011

lt0001

lt0001

Antihypertensive medications BL

Antihypertensive medications Y1

Y1 ndash Baseline

753

752

-01

737

759

22

023

054

002

1-Year Changes in Markers of Lipid

Control

Markers of Lipid Control ILI DSE P-value

LDL-cholesterol (mgdl) BL

LDL-cholesterol (mgdl) Y1

Y1 ndash Baseline

1122

1070

-52

1124

1067

-57

078

074

049

HDL-cholesterol (mgdl) BL

HDL-cholesterol (mgdl) Y1

Y1 ndash Baseline

435

469

34

436

449

14

080

lt0001

lt0001

Triglycerides (mgdl) BL

Triglycerides (mgdl) Y1

Y1 ndash Baseline

1828

1525

-303

1800

1654

-146

038

lt0001

lt0001

Lipid lowering medications BL

Lipid lowering medications Y1

Y1 ndash Baseline

494

530

37

484

578

94

052

lt0001

lt0001

1-Year Changes in Percent of Participants

Meeting ADA Goals

ADA Goal ILI DSE P-value

Hemoglobin A1c lt 7 BL

Hemoglobin A1c lt 7 Y1

Y1 ndash Baseline

463

727

264

454

508

54

050

lt0001

lt0001

Blood pressure lt 13080 mmHg BL

Blood pressure lt 13080 mmHg Y1

Y1 ndash Baseline

535

686

151

499

570

70

001

lt0001

lt0001

LDL-cholesterol lt 100 mgdl BL

LDL-cholesterol lt 100 mgdl Y1

Y1 ndash Baseline

371

438

67

369

449

80

087

045

034

All three goals BL

All three goals Y1

Y1 ndash Baseline

108

236

128

95

160

65

013

lt0001

lt0001

Mean Changes in Weight Fitness amp BP

Averaged Over Four Years

DSE

Mean

ILI

Mean

P-value

Weight Loss

( initial wt)

-088 -615 lt 00001

Fitness

( METS)

196 1274 lt00001

HbA1c -009 -036 lt 00001

SBP (mm Hg) -297 -533 lt 00001

DBP (mm Hg) -248 -292 0012

Look AHEAD Research Group Arch Int Med 2010

Mean Changes in Lipid Profile

Averaged Over Four Years

DSE

Mean

ILI

Mean

P-value

HDL (mgdl) 197 367 lt00001

TG (mgdl) -1975 -2556 00006

LDL (mgdl) -1284 -1127 0009

LDL (mgdl)

(Adjusting for

medication use)

-922 -875 042

Look AHEAD Research Group Arch Int Med 2010

Percent () Completing Outcome

Measures at Years 1-4

Intervention Group

(ILI)

Year 1 971

Year 2 949

Year 3 940

Year 4 941

Comparison Group

(DSE)

Year 1 957

Year 2 935

Year 3 938

Year 4 931

Look AHEAD Summary

ILI had significantly greater improvements than DSE in all CVD risk factors averaged across 4 years (except LDL-C)

There may be long-term beneficial effects from this 4-year period in which ILI subjects have been exposed to lower CVD risk factors

Longer follow-ups will determine whether these lowered CVD risk factors can be maintained amp whether lifestyle intervention has positive effects on CVD morbidity amp mortality

Mary J

Female

White

56 years old at start of Look AHEAD

study

Past Medical History Type 2 diabetes

overweight diverticulosis arthritis

sleep apnea back pain

Mary J

bullLong term strugglesbull Helping youngest daughter with

personal issues and children

bull Rotator cuff problems

bull Degenerative disks in back

bull Rheumatoid arthritis

bull Diabetes

bull Physically demanding job

bull Financial struggles

Pounds

Years

82007 grandkids enter pre-school

Catherine L

Female

White

47 years old at start of Look AHEAD

study

Past Medical History Type 2 diabetes

overweight high blood pressure

hypothyroidism back pain

Catherine L

Long term struggles

bull Motherrsquos declining health and death

bull Multiple serious injuries

bull Sudden death of sister

bull Death of step-father

bull Declining economy

bull Children living at home

Pounds

Years

Realistic Management Goals

5-10 weight loss

Health energy and fitness

Well-being and self-esteem

Mood and appearance

Functional and recreational

activity

Key Elements

Focus on health and energy

Food and physical activity diaries

Gradual increase in physical activity

Gradual reduction in dietary fat

No feelings of food deprivation

Social support groups

Recommended Strategies for Building

Sustainable Healthy Communities

Overview from USA

Promote the availability of affordable healthy

food and beverages

Support healthy food and beverage choices

Encourage breastfeeding

Encourage physical activity or limit sedentary

activity among children amp youth

Create safe communities that support physical

activity

Encourage communities to organize for change

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Increase the availability of healthier food and

beverage choices in public service venues (eg

schools city amp county buildings etc)

--Insufficient evidence in school-based programs

--Associations suggest availability amp increased

consumption

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve availability of affordable healthier

food amp beverage choices in public service

venues

--Reducing the cost of healthier foods

increases their purchase

--Providing coupons redeemable for

healthier foods increases their purchase

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve geographic availability of

supermarkets in underserved areas

-- Greater access to nearby supermarkets is

associated with healthier eating behaviors

-- Increasing the number of supermarkets in

underserved neighborhoods increased

real estate values increased economic

activity amp employment amp resulted in lower

food prices

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Provide incentives to food retailers to locate in

andor offer healthier food choices in

underserved areas

-- Presence of retail venues that provide healthier

foods is associated with better nutrition

-- Greater availability of supermarkets was

associated with lower adolescent BMI scores

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Improve availability of mechanisms for

purchasing foods from farms

--Evidence supporting a direct link between

purchasing food from farms amp improved diet is

limited

--Two studies of initiatives to encourage

participation in farmersrsquo market showed

increased intention to eat more fruits amp

vegetables but no direct evidence

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Provide incentives for the production

distribution and procurement of foods from local

farms

--No evidence has been published to link local

food production amp health outcomes

--There is a current study exploring the potential

nutritional amp health benefits of eating locally

grown foods

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Restrict availability of less healthy foods amp

beverages in public service venues

--No peer-reviewed studies examined the impact

designed to restrict availability of less healthy

foods in public service venues

--21 states have policies that restrict the sale of

competitive foods in schools beyond USDA

regulations however no studies have evaluated

the impact of the policies

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Institute smaller portion size options in public

service venues

--Evidence is lacking to demonstrate effectiveness

of population-based interventions aimed at

reducing portion sizes in public service venues

--Evidence from clinical studies in laboratories

demonstrates decreasing portion sizes

decreases energy intake

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Limit advertisements of less healthy foods amp

beverages

--Little evidence is available regarding the impact

of restricting advertising on purchasing amp

consumption of less healthy foods

--Cross-sectional time-series studies of tobacco-

control efforts suggest an association between

advertising bans amp decreased tobacco

consumption

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Discourage consumption of sugar-sweetened

beverages

--One longitudinal study of a school-based

intervention among Native-American high school

students showed a substantial reduction in

sugar-sweetened beverages over a 3-year

period

--A RCT of a home-based intervention that

eliminated sugar-sweetened beverages showed

reduction in BMI scores

Recommended Community Strategies Strategies to encourage breastfeeding

Increase support for breastfeeding

--Evidence directly linking environmental

interventions that support breastfeeding with

obesity-related outcomes is lacking

--Epidemiologic studies indicate that breastfeeding

helps prevent pediatric obesity

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Require physical education in schools

--14 studies have demonstrated that school-based

PE was effective in increasing levels of physical

activity and improving physical fitness

--Minimum of 150 minwk in elementary schools

225 minwk in middle schools and high schools

throughout the school year as recommended by

NASPE

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Increase opportunities for extracurricular

physical activity

--Participation in after-school programs increased

studentsrsquo level of physical activity amp improved

obesity-related outcomes (improved CV fitness

reduced body fat)

--2 pilot studies providing extracurricular physical

activity showed increased levels of PA amp

decreased sedentary behavior

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Reduce screen time in public service venues

--A school-based RCT indicated that children who

reduced their television videotape amp video

game use had significant decrease in BMI tricep

skin fold thickness amp waist circumference

compared to controls

--Spending less time watching television is

associated with increased physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Improve access to outdoor recreational

facilities

--Review of 108 studies indicated that access to facilities

and programs for recreation near their homes amp time

spent outdoors correlated positively with increased

physical activity among childrenamp adults

--Perceptions that footpaths are safe for walking was

significantly associated with adults being classified as

physically active at a level sufficient for health benefits

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting

bicycling

--Longitudinal intervention studies have

demonstrated that improving bicycling

infrastructure is associated with increased

frequency of bicycling

--Cross-sectional studies indicated a significant

association between bicycling infrastructure amp

frequency of biking

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting walking

--Reviews of cross-sectional studies of

environmental correlates of physical activity amp

walking generally find a positive association

between infrastructure supportive of walking amp

physical activity

--Identifying amp creating safe routes to school

together with educational components

increased the number of students walking to

school

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Locating schools within easy walking

distance of residential areas

--Community-scale urban design amp land use policies amp

practices including locating schools stores workplaces

amp recreation areas close to residential areas are

effective in facilitating an increase in levels of physical

activity

--Majority of efforts to encourage walking to school involve

improving the routes rather than improving the location

of schools

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Improve access to public transportation

--Insufficient evidence exists to determine

effectiveness of transportation policies in

increasing the level of physical activity or

improving fitness

--1 study indicated that 29 of individuals who

walk to and from public transit achieve at least

30 minutes of daily physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Zone for mixed-use development

--Allows residential commercial institutional amp

other public land uses to be located in close

proximity to one another

--Studies using correlation analyses amp regression

models indicated that mixed land use was

associated with increased walking amp cycling

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance personal safety in areas where

persons are or could be physically active

--Cross-sectional studies have demonstrated a

negative relationship between crime rates andor

perceived safety amp physical activity in

neighborhoods

--Few intervention studies have evaluated the

impact of policies amp practices to improve

personal safety on physical activity

Geospatial Mapping Linking Urban

Environments to Health Risk

Measure association between environmental variables amp health risk factors

Assess relationships between variables at different levels of analysis

Used in conjunction with linear analyses

Our Community Environmental Model

of Obesity

Community Factors

Poverty

Crime

Grocery Quality

Restaurants

Parks

Sidewalks

Fast Food Outlets

Recreational

Facilities

Individual Factors

Dietary Intake

Physical Activity

Genetics

Family History

StressCoping

Eating Disorders

Psychological

Problems

Weight

Status

Chosen Neighborhoods

Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped

We then matched census-block groups within the income groups by population density and percentage of minority representation

One matched block group per income level was randomly selected

Prevalence of Obesity in

Block-Groups

0

5

10

15

20

25

30

35

40

45

50

Ag

e-a

dju

sted

Ob

esit

y P

rev

ale

nce

(

)

High-Income Low-Income

Age-standardized to the 1990 US Census

Density of Environmental Factors in the

Community Contributes to a ldquoToxicrdquo

Obesity Environment

0

2

4

6

8

10

12

14

16

18

Fast-food Convenience Store Bars

Den

sity

10

00

perso

ns

High-Income Low-Income

COMMUNITYrsquoS PERCEPTION OF SAFETY

0

5

10

15

20

25

30

35

40

Daytime Nighttime

Perc

en

t (

) F

eeli

ng

So

mew

hat

Safe

or

Un

safe

Low-Income High-Income

Percent Substandard (or worse) Housing

or Ground Conditions

of Residential Properties

0

10

20

30

Structural Grounds

Perc

en

t (

)

Low-Income High-Income

CONCLUSIONS

These data suggest that the higher

frequency of outlets providing

calorically-dense foods and alcohol may

contribute to greater obesity prevalence

in residents of low-income communities

More research is needed to thoroughly

document environmental determinants

of health and obesity

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

From 1994-1998 HUD randomly assigned

4498 women with children living in public

housing in high-poverty urban census

tracts to one of three groups (1) housing

vouchers redeemable only if they moved

to a low-poverty census tract (2)

unrestricted vouchers or (3) control group

(no vouchers)

Ludwig et al NEJM 201136516

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

10-12 year follow-up showed modest but

potentially important reductions in the

prevalence of extreme obesity amp diabetes in the

group moving from a neighborhood with high

poverty on one of low poverty compared to the

control group

No differences between the group receiving

traditional vouchers amp the control group

ldquoNeighborhoods matterrdquo

Ludwig et al NEJM 201136516

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance traffic safety in areas where

persons are or could be physically active

--Community-scale urban design amp land use policies to

promote physical activity including design components

to improve street lighting infrastructure projects to

increase safety of pedestrian street crossing and use of

traffic calming approaches such as speed humps amp

traffic circles are effective in increasing physical activity

--Both community-scale amp street-scale policies amp practices

are effective in increasing physical activity

Recommended Community Strategies Encourage Communities to Organize for Change

Participate in community coalitions or

partnerships to address obesity

--Little evidence is available to determine the

impact of community coalitions on obesity

prevention

--The presence of anti-smoking community

coalitions has been associated with lower rates

of tobacco consumption

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

$103 million awarded to 61 states and

communities including state amp local government

agencies tribes amp territories amp state amp local non-

profit organizations

To build capacity to implement changes for

community prevention efforts to ensure long-

term success

To implement evidence-based and practice-

based programs to improve health amp wellness

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Priority areas are

Tobacco-free living

Active living and healthy eating

Evidence-based quality clinical and other

preventive health services for prevention

and control of high blood pressure and

high cholesterol

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Applicants proposed specific activities in

line with their chosen priority areas in their

applications

Grantee activities will not be finalized until

plans are negotiated with CDC by early

2012

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Capacity-Building Award

The Confederated Tribes of The Chehalis

Reservation is receiving a $498663 planning

award to build capacity to support healthy

lifestyles among their tribal population of 1500

in Washington State

Work will target tobacco-free living active living

and healthy eating and quality clinical and other

healthy serviceswwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Implementation Award

Austin TX Dept of Health and Human Services

is receiving $1026158 to serve Travis County

(Austin) to expand efforts in tobacco-free living

active living and healthy eating quality clinical

and other preventive services social and

emotional wellness and healthy and safe

physical environmentswwwcdcgov1052011

Building sustainable healthy

communities Bottom line

Obesity is an environmental problem

Despite progress in genetic research public health advances only will occur when we take the environment seriously

Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment

Until we do this we will not make substantial progress in addressing the epidemic of obesity

Poston amp Foreyt Atherosclerosis 1999

Whatrsquos the best approach

Integrate all sectors of society into community

change interventions

Incorporate

Science amp Technology

Education

FamilyCommunity

Healthcare

Arts amp Entertainment

Law amp Politics

Commerce amp Trade

Sectors of Society

Arts amp Entertainm

ent

Commerce amp Trade

Education

FamilyCommunity

Healthcare

Law amp Politics

Science amp Technology

Project FIT rationale design and baseline characteristics of a school- and community-

based intervention to address physical activity and healthy eating among low-income

elementary school children

Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D

Oh HJ Orth J Randall S Mayfield K Holmes D

Source

Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu

Abstract

BACKGROUND

This paper describes Project FIT a collaboration between the public school system local

health systems physicians neighborhood associations businesses faith-based leaders

community agencies and university researchers to develop a multi-faceted approach to

promote physical activity and healthy eating toward the general goal of preventing and

reducing childhood obesity among children in Grand Rapids MI USA

METHODSDESIGN

There are four overall components to Project FIT school community social marketing and

school staff wellness - all that focus on 1) increasing access to safe and affordable physical

activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)

improving the affordability and availability of nutritious food in the neighborhoods surrounding

the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding

nutrition and physical activity among school staff parents and students 4) impacting the

culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging

dialogue among all community partners to leverage existing programs and introduce new

ones

Winston-Salem

Baltimore

Philadelphia

New York

Providence

Boston

Clinical Site Coordinating Center

Clinical Sites

Seattle

Los Angeles

San AntonioHouston

Baton Rouge

Minneapolis

Memphis

Birmingham

Pittsburgh

Denver

Phoenix

Look AHEADParticipants

101100Baseline weight (kg)

589586Age (years)

9496Attended 1 year exam

360359Baseline BMI

1514Insulin Users

3737Minority

6059Women

(N=2574)(N=2630)

DSELifestyle

p lt 0004

Look AHEAD

Study Interventions

bull Diabetes support and education - DSE (control group)

bull Lifestyle intervention ndash ILI (treatment group)

Look AHEAD

Lifestyle Intervention

Goals

bull 7 weight loss for the group (10

for individual)

bull 175 minutes of moderate intensity

activity

Look AHEAD

Lifestyle Intervention

bull Diet

ndash ADA NCEP (lt 30 fat lt 10 sat fat

gt15 protein)

ndash 1200-1500 (if weight lt250lbs)

ndash 1500-1800 (if weight gt250lbs)

ndash During first 4 weeks to 4 months portion

control (liquid meal replacements or

structured meal plan)

Look AHEAD

Lifestyle Intervention

bull Physical Activity

ndash unsupervised

ndash 175 minutes moderate intensityweek

ndash 5 daysweek

ndash walking

Weight Loss at 1-Year

-9

ILI 0

-1

-2

-3

-4

-5

-6

-7

-8

DSE

p lt 00001

W

eig

ht

Chan

ge

86

07

The Look AHEAD Research Group Diabetes Care 2007

Reduction in Initial Weight by Gender

N=872

N=1229N=1197

N=830

-12

-10

-8

-6

-4

-2

0

0 2 4 6 8 10 12

Months

R

ed

uctio

n in

In

itia

l W

eig

ht

Men

Women

Plt0001

The Look AHEAD Research Group Diabetes Care 2007

Fitness Change () at 1-Year

0

5

10

15

20

25

Mean

Fitness C

hange

Unadjusted

Plt0001Adjusted for 1 Year

Weight Change Plt0001

58

209

108

159

DSE ILI ILIDSE

The Look AHEAD Research Group Diabetes Care 2007

1-Year Changes in Markers of

Diabetes Control

Markers of Diabetes

Control ILI DSE P-value

Hemoglobin A1c () BL

Hemoglobin A1c () Y1

Y1 ndash Baseline

725

661

-064

729

715

-014

026

lt0001

lt0001

Fasting glucose (mgdl) BL

Fasting glucose (mgdl) Y1

Y1 ndash Baseline

1519

1304

-215

1536

1464

-72

021

lt0001

lt0001

Diabetes medications BL

Diabetes medications Y1

Y1 ndash Baseline

865

786

-78

865

887

22

093

lt0001

lt0001

1-Year Changes in Markers of

Blood Pressure ControlMarkers of Blood Pressure

Control ILI DSE P-value

Systolic BP (mmHg) BL

Systolic BP (mmHg) Y1

Y1 ndash Baseline

1282

1214

-68

1294

1266

-28

026

lt0001

lt0001

Diastolic BP (mmHg) BL

Diastolic BP (mmHg) Y1

Y1 ndash Baseline

699

670

-30

704

686

-18

011

lt0001

lt0001

Antihypertensive medications BL

Antihypertensive medications Y1

Y1 ndash Baseline

753

752

-01

737

759

22

023

054

002

1-Year Changes in Markers of Lipid

Control

Markers of Lipid Control ILI DSE P-value

LDL-cholesterol (mgdl) BL

LDL-cholesterol (mgdl) Y1

Y1 ndash Baseline

1122

1070

-52

1124

1067

-57

078

074

049

HDL-cholesterol (mgdl) BL

HDL-cholesterol (mgdl) Y1

Y1 ndash Baseline

435

469

34

436

449

14

080

lt0001

lt0001

Triglycerides (mgdl) BL

Triglycerides (mgdl) Y1

Y1 ndash Baseline

1828

1525

-303

1800

1654

-146

038

lt0001

lt0001

Lipid lowering medications BL

Lipid lowering medications Y1

Y1 ndash Baseline

494

530

37

484

578

94

052

lt0001

lt0001

1-Year Changes in Percent of Participants

Meeting ADA Goals

ADA Goal ILI DSE P-value

Hemoglobin A1c lt 7 BL

Hemoglobin A1c lt 7 Y1

Y1 ndash Baseline

463

727

264

454

508

54

050

lt0001

lt0001

Blood pressure lt 13080 mmHg BL

Blood pressure lt 13080 mmHg Y1

Y1 ndash Baseline

535

686

151

499

570

70

001

lt0001

lt0001

LDL-cholesterol lt 100 mgdl BL

LDL-cholesterol lt 100 mgdl Y1

Y1 ndash Baseline

371

438

67

369

449

80

087

045

034

All three goals BL

All three goals Y1

Y1 ndash Baseline

108

236

128

95

160

65

013

lt0001

lt0001

Mean Changes in Weight Fitness amp BP

Averaged Over Four Years

DSE

Mean

ILI

Mean

P-value

Weight Loss

( initial wt)

-088 -615 lt 00001

Fitness

( METS)

196 1274 lt00001

HbA1c -009 -036 lt 00001

SBP (mm Hg) -297 -533 lt 00001

DBP (mm Hg) -248 -292 0012

Look AHEAD Research Group Arch Int Med 2010

Mean Changes in Lipid Profile

Averaged Over Four Years

DSE

Mean

ILI

Mean

P-value

HDL (mgdl) 197 367 lt00001

TG (mgdl) -1975 -2556 00006

LDL (mgdl) -1284 -1127 0009

LDL (mgdl)

(Adjusting for

medication use)

-922 -875 042

Look AHEAD Research Group Arch Int Med 2010

Percent () Completing Outcome

Measures at Years 1-4

Intervention Group

(ILI)

Year 1 971

Year 2 949

Year 3 940

Year 4 941

Comparison Group

(DSE)

Year 1 957

Year 2 935

Year 3 938

Year 4 931

Look AHEAD Summary

ILI had significantly greater improvements than DSE in all CVD risk factors averaged across 4 years (except LDL-C)

There may be long-term beneficial effects from this 4-year period in which ILI subjects have been exposed to lower CVD risk factors

Longer follow-ups will determine whether these lowered CVD risk factors can be maintained amp whether lifestyle intervention has positive effects on CVD morbidity amp mortality

Mary J

Female

White

56 years old at start of Look AHEAD

study

Past Medical History Type 2 diabetes

overweight diverticulosis arthritis

sleep apnea back pain

Mary J

bullLong term strugglesbull Helping youngest daughter with

personal issues and children

bull Rotator cuff problems

bull Degenerative disks in back

bull Rheumatoid arthritis

bull Diabetes

bull Physically demanding job

bull Financial struggles

Pounds

Years

82007 grandkids enter pre-school

Catherine L

Female

White

47 years old at start of Look AHEAD

study

Past Medical History Type 2 diabetes

overweight high blood pressure

hypothyroidism back pain

Catherine L

Long term struggles

bull Motherrsquos declining health and death

bull Multiple serious injuries

bull Sudden death of sister

bull Death of step-father

bull Declining economy

bull Children living at home

Pounds

Years

Realistic Management Goals

5-10 weight loss

Health energy and fitness

Well-being and self-esteem

Mood and appearance

Functional and recreational

activity

Key Elements

Focus on health and energy

Food and physical activity diaries

Gradual increase in physical activity

Gradual reduction in dietary fat

No feelings of food deprivation

Social support groups

Recommended Strategies for Building

Sustainable Healthy Communities

Overview from USA

Promote the availability of affordable healthy

food and beverages

Support healthy food and beverage choices

Encourage breastfeeding

Encourage physical activity or limit sedentary

activity among children amp youth

Create safe communities that support physical

activity

Encourage communities to organize for change

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Increase the availability of healthier food and

beverage choices in public service venues (eg

schools city amp county buildings etc)

--Insufficient evidence in school-based programs

--Associations suggest availability amp increased

consumption

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve availability of affordable healthier

food amp beverage choices in public service

venues

--Reducing the cost of healthier foods

increases their purchase

--Providing coupons redeemable for

healthier foods increases their purchase

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve geographic availability of

supermarkets in underserved areas

-- Greater access to nearby supermarkets is

associated with healthier eating behaviors

-- Increasing the number of supermarkets in

underserved neighborhoods increased

real estate values increased economic

activity amp employment amp resulted in lower

food prices

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Provide incentives to food retailers to locate in

andor offer healthier food choices in

underserved areas

-- Presence of retail venues that provide healthier

foods is associated with better nutrition

-- Greater availability of supermarkets was

associated with lower adolescent BMI scores

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Improve availability of mechanisms for

purchasing foods from farms

--Evidence supporting a direct link between

purchasing food from farms amp improved diet is

limited

--Two studies of initiatives to encourage

participation in farmersrsquo market showed

increased intention to eat more fruits amp

vegetables but no direct evidence

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Provide incentives for the production

distribution and procurement of foods from local

farms

--No evidence has been published to link local

food production amp health outcomes

--There is a current study exploring the potential

nutritional amp health benefits of eating locally

grown foods

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Restrict availability of less healthy foods amp

beverages in public service venues

--No peer-reviewed studies examined the impact

designed to restrict availability of less healthy

foods in public service venues

--21 states have policies that restrict the sale of

competitive foods in schools beyond USDA

regulations however no studies have evaluated

the impact of the policies

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Institute smaller portion size options in public

service venues

--Evidence is lacking to demonstrate effectiveness

of population-based interventions aimed at

reducing portion sizes in public service venues

--Evidence from clinical studies in laboratories

demonstrates decreasing portion sizes

decreases energy intake

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Limit advertisements of less healthy foods amp

beverages

--Little evidence is available regarding the impact

of restricting advertising on purchasing amp

consumption of less healthy foods

--Cross-sectional time-series studies of tobacco-

control efforts suggest an association between

advertising bans amp decreased tobacco

consumption

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Discourage consumption of sugar-sweetened

beverages

--One longitudinal study of a school-based

intervention among Native-American high school

students showed a substantial reduction in

sugar-sweetened beverages over a 3-year

period

--A RCT of a home-based intervention that

eliminated sugar-sweetened beverages showed

reduction in BMI scores

Recommended Community Strategies Strategies to encourage breastfeeding

Increase support for breastfeeding

--Evidence directly linking environmental

interventions that support breastfeeding with

obesity-related outcomes is lacking

--Epidemiologic studies indicate that breastfeeding

helps prevent pediatric obesity

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Require physical education in schools

--14 studies have demonstrated that school-based

PE was effective in increasing levels of physical

activity and improving physical fitness

--Minimum of 150 minwk in elementary schools

225 minwk in middle schools and high schools

throughout the school year as recommended by

NASPE

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Increase opportunities for extracurricular

physical activity

--Participation in after-school programs increased

studentsrsquo level of physical activity amp improved

obesity-related outcomes (improved CV fitness

reduced body fat)

--2 pilot studies providing extracurricular physical

activity showed increased levels of PA amp

decreased sedentary behavior

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Reduce screen time in public service venues

--A school-based RCT indicated that children who

reduced their television videotape amp video

game use had significant decrease in BMI tricep

skin fold thickness amp waist circumference

compared to controls

--Spending less time watching television is

associated with increased physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Improve access to outdoor recreational

facilities

--Review of 108 studies indicated that access to facilities

and programs for recreation near their homes amp time

spent outdoors correlated positively with increased

physical activity among childrenamp adults

--Perceptions that footpaths are safe for walking was

significantly associated with adults being classified as

physically active at a level sufficient for health benefits

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting

bicycling

--Longitudinal intervention studies have

demonstrated that improving bicycling

infrastructure is associated with increased

frequency of bicycling

--Cross-sectional studies indicated a significant

association between bicycling infrastructure amp

frequency of biking

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting walking

--Reviews of cross-sectional studies of

environmental correlates of physical activity amp

walking generally find a positive association

between infrastructure supportive of walking amp

physical activity

--Identifying amp creating safe routes to school

together with educational components

increased the number of students walking to

school

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Locating schools within easy walking

distance of residential areas

--Community-scale urban design amp land use policies amp

practices including locating schools stores workplaces

amp recreation areas close to residential areas are

effective in facilitating an increase in levels of physical

activity

--Majority of efforts to encourage walking to school involve

improving the routes rather than improving the location

of schools

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Improve access to public transportation

--Insufficient evidence exists to determine

effectiveness of transportation policies in

increasing the level of physical activity or

improving fitness

--1 study indicated that 29 of individuals who

walk to and from public transit achieve at least

30 minutes of daily physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Zone for mixed-use development

--Allows residential commercial institutional amp

other public land uses to be located in close

proximity to one another

--Studies using correlation analyses amp regression

models indicated that mixed land use was

associated with increased walking amp cycling

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance personal safety in areas where

persons are or could be physically active

--Cross-sectional studies have demonstrated a

negative relationship between crime rates andor

perceived safety amp physical activity in

neighborhoods

--Few intervention studies have evaluated the

impact of policies amp practices to improve

personal safety on physical activity

Geospatial Mapping Linking Urban

Environments to Health Risk

Measure association between environmental variables amp health risk factors

Assess relationships between variables at different levels of analysis

Used in conjunction with linear analyses

Our Community Environmental Model

of Obesity

Community Factors

Poverty

Crime

Grocery Quality

Restaurants

Parks

Sidewalks

Fast Food Outlets

Recreational

Facilities

Individual Factors

Dietary Intake

Physical Activity

Genetics

Family History

StressCoping

Eating Disorders

Psychological

Problems

Weight

Status

Chosen Neighborhoods

Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped

We then matched census-block groups within the income groups by population density and percentage of minority representation

One matched block group per income level was randomly selected

Prevalence of Obesity in

Block-Groups

0

5

10

15

20

25

30

35

40

45

50

Ag

e-a

dju

sted

Ob

esit

y P

rev

ale

nce

(

)

High-Income Low-Income

Age-standardized to the 1990 US Census

Density of Environmental Factors in the

Community Contributes to a ldquoToxicrdquo

Obesity Environment

0

2

4

6

8

10

12

14

16

18

Fast-food Convenience Store Bars

Den

sity

10

00

perso

ns

High-Income Low-Income

COMMUNITYrsquoS PERCEPTION OF SAFETY

0

5

10

15

20

25

30

35

40

Daytime Nighttime

Perc

en

t (

) F

eeli

ng

So

mew

hat

Safe

or

Un

safe

Low-Income High-Income

Percent Substandard (or worse) Housing

or Ground Conditions

of Residential Properties

0

10

20

30

Structural Grounds

Perc

en

t (

)

Low-Income High-Income

CONCLUSIONS

These data suggest that the higher

frequency of outlets providing

calorically-dense foods and alcohol may

contribute to greater obesity prevalence

in residents of low-income communities

More research is needed to thoroughly

document environmental determinants

of health and obesity

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

From 1994-1998 HUD randomly assigned

4498 women with children living in public

housing in high-poverty urban census

tracts to one of three groups (1) housing

vouchers redeemable only if they moved

to a low-poverty census tract (2)

unrestricted vouchers or (3) control group

(no vouchers)

Ludwig et al NEJM 201136516

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

10-12 year follow-up showed modest but

potentially important reductions in the

prevalence of extreme obesity amp diabetes in the

group moving from a neighborhood with high

poverty on one of low poverty compared to the

control group

No differences between the group receiving

traditional vouchers amp the control group

ldquoNeighborhoods matterrdquo

Ludwig et al NEJM 201136516

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance traffic safety in areas where

persons are or could be physically active

--Community-scale urban design amp land use policies to

promote physical activity including design components

to improve street lighting infrastructure projects to

increase safety of pedestrian street crossing and use of

traffic calming approaches such as speed humps amp

traffic circles are effective in increasing physical activity

--Both community-scale amp street-scale policies amp practices

are effective in increasing physical activity

Recommended Community Strategies Encourage Communities to Organize for Change

Participate in community coalitions or

partnerships to address obesity

--Little evidence is available to determine the

impact of community coalitions on obesity

prevention

--The presence of anti-smoking community

coalitions has been associated with lower rates

of tobacco consumption

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

$103 million awarded to 61 states and

communities including state amp local government

agencies tribes amp territories amp state amp local non-

profit organizations

To build capacity to implement changes for

community prevention efforts to ensure long-

term success

To implement evidence-based and practice-

based programs to improve health amp wellness

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Priority areas are

Tobacco-free living

Active living and healthy eating

Evidence-based quality clinical and other

preventive health services for prevention

and control of high blood pressure and

high cholesterol

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Applicants proposed specific activities in

line with their chosen priority areas in their

applications

Grantee activities will not be finalized until

plans are negotiated with CDC by early

2012

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Capacity-Building Award

The Confederated Tribes of The Chehalis

Reservation is receiving a $498663 planning

award to build capacity to support healthy

lifestyles among their tribal population of 1500

in Washington State

Work will target tobacco-free living active living

and healthy eating and quality clinical and other

healthy serviceswwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Implementation Award

Austin TX Dept of Health and Human Services

is receiving $1026158 to serve Travis County

(Austin) to expand efforts in tobacco-free living

active living and healthy eating quality clinical

and other preventive services social and

emotional wellness and healthy and safe

physical environmentswwwcdcgov1052011

Building sustainable healthy

communities Bottom line

Obesity is an environmental problem

Despite progress in genetic research public health advances only will occur when we take the environment seriously

Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment

Until we do this we will not make substantial progress in addressing the epidemic of obesity

Poston amp Foreyt Atherosclerosis 1999

Whatrsquos the best approach

Integrate all sectors of society into community

change interventions

Incorporate

Science amp Technology

Education

FamilyCommunity

Healthcare

Arts amp Entertainment

Law amp Politics

Commerce amp Trade

Sectors of Society

Arts amp Entertainm

ent

Commerce amp Trade

Education

FamilyCommunity

Healthcare

Law amp Politics

Science amp Technology

Project FIT rationale design and baseline characteristics of a school- and community-

based intervention to address physical activity and healthy eating among low-income

elementary school children

Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D

Oh HJ Orth J Randall S Mayfield K Holmes D

Source

Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu

Abstract

BACKGROUND

This paper describes Project FIT a collaboration between the public school system local

health systems physicians neighborhood associations businesses faith-based leaders

community agencies and university researchers to develop a multi-faceted approach to

promote physical activity and healthy eating toward the general goal of preventing and

reducing childhood obesity among children in Grand Rapids MI USA

METHODSDESIGN

There are four overall components to Project FIT school community social marketing and

school staff wellness - all that focus on 1) increasing access to safe and affordable physical

activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)

improving the affordability and availability of nutritious food in the neighborhoods surrounding

the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding

nutrition and physical activity among school staff parents and students 4) impacting the

culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging

dialogue among all community partners to leverage existing programs and introduce new

ones

Look AHEADParticipants

101100Baseline weight (kg)

589586Age (years)

9496Attended 1 year exam

360359Baseline BMI

1514Insulin Users

3737Minority

6059Women

(N=2574)(N=2630)

DSELifestyle

p lt 0004

Look AHEAD

Study Interventions

bull Diabetes support and education - DSE (control group)

bull Lifestyle intervention ndash ILI (treatment group)

Look AHEAD

Lifestyle Intervention

Goals

bull 7 weight loss for the group (10

for individual)

bull 175 minutes of moderate intensity

activity

Look AHEAD

Lifestyle Intervention

bull Diet

ndash ADA NCEP (lt 30 fat lt 10 sat fat

gt15 protein)

ndash 1200-1500 (if weight lt250lbs)

ndash 1500-1800 (if weight gt250lbs)

ndash During first 4 weeks to 4 months portion

control (liquid meal replacements or

structured meal plan)

Look AHEAD

Lifestyle Intervention

bull Physical Activity

ndash unsupervised

ndash 175 minutes moderate intensityweek

ndash 5 daysweek

ndash walking

Weight Loss at 1-Year

-9

ILI 0

-1

-2

-3

-4

-5

-6

-7

-8

DSE

p lt 00001

W

eig

ht

Chan

ge

86

07

The Look AHEAD Research Group Diabetes Care 2007

Reduction in Initial Weight by Gender

N=872

N=1229N=1197

N=830

-12

-10

-8

-6

-4

-2

0

0 2 4 6 8 10 12

Months

R

ed

uctio

n in

In

itia

l W

eig

ht

Men

Women

Plt0001

The Look AHEAD Research Group Diabetes Care 2007

Fitness Change () at 1-Year

0

5

10

15

20

25

Mean

Fitness C

hange

Unadjusted

Plt0001Adjusted for 1 Year

Weight Change Plt0001

58

209

108

159

DSE ILI ILIDSE

The Look AHEAD Research Group Diabetes Care 2007

1-Year Changes in Markers of

Diabetes Control

Markers of Diabetes

Control ILI DSE P-value

Hemoglobin A1c () BL

Hemoglobin A1c () Y1

Y1 ndash Baseline

725

661

-064

729

715

-014

026

lt0001

lt0001

Fasting glucose (mgdl) BL

Fasting glucose (mgdl) Y1

Y1 ndash Baseline

1519

1304

-215

1536

1464

-72

021

lt0001

lt0001

Diabetes medications BL

Diabetes medications Y1

Y1 ndash Baseline

865

786

-78

865

887

22

093

lt0001

lt0001

1-Year Changes in Markers of

Blood Pressure ControlMarkers of Blood Pressure

Control ILI DSE P-value

Systolic BP (mmHg) BL

Systolic BP (mmHg) Y1

Y1 ndash Baseline

1282

1214

-68

1294

1266

-28

026

lt0001

lt0001

Diastolic BP (mmHg) BL

Diastolic BP (mmHg) Y1

Y1 ndash Baseline

699

670

-30

704

686

-18

011

lt0001

lt0001

Antihypertensive medications BL

Antihypertensive medications Y1

Y1 ndash Baseline

753

752

-01

737

759

22

023

054

002

1-Year Changes in Markers of Lipid

Control

Markers of Lipid Control ILI DSE P-value

LDL-cholesterol (mgdl) BL

LDL-cholesterol (mgdl) Y1

Y1 ndash Baseline

1122

1070

-52

1124

1067

-57

078

074

049

HDL-cholesterol (mgdl) BL

HDL-cholesterol (mgdl) Y1

Y1 ndash Baseline

435

469

34

436

449

14

080

lt0001

lt0001

Triglycerides (mgdl) BL

Triglycerides (mgdl) Y1

Y1 ndash Baseline

1828

1525

-303

1800

1654

-146

038

lt0001

lt0001

Lipid lowering medications BL

Lipid lowering medications Y1

Y1 ndash Baseline

494

530

37

484

578

94

052

lt0001

lt0001

1-Year Changes in Percent of Participants

Meeting ADA Goals

ADA Goal ILI DSE P-value

Hemoglobin A1c lt 7 BL

Hemoglobin A1c lt 7 Y1

Y1 ndash Baseline

463

727

264

454

508

54

050

lt0001

lt0001

Blood pressure lt 13080 mmHg BL

Blood pressure lt 13080 mmHg Y1

Y1 ndash Baseline

535

686

151

499

570

70

001

lt0001

lt0001

LDL-cholesterol lt 100 mgdl BL

LDL-cholesterol lt 100 mgdl Y1

Y1 ndash Baseline

371

438

67

369

449

80

087

045

034

All three goals BL

All three goals Y1

Y1 ndash Baseline

108

236

128

95

160

65

013

lt0001

lt0001

Mean Changes in Weight Fitness amp BP

Averaged Over Four Years

DSE

Mean

ILI

Mean

P-value

Weight Loss

( initial wt)

-088 -615 lt 00001

Fitness

( METS)

196 1274 lt00001

HbA1c -009 -036 lt 00001

SBP (mm Hg) -297 -533 lt 00001

DBP (mm Hg) -248 -292 0012

Look AHEAD Research Group Arch Int Med 2010

Mean Changes in Lipid Profile

Averaged Over Four Years

DSE

Mean

ILI

Mean

P-value

HDL (mgdl) 197 367 lt00001

TG (mgdl) -1975 -2556 00006

LDL (mgdl) -1284 -1127 0009

LDL (mgdl)

(Adjusting for

medication use)

-922 -875 042

Look AHEAD Research Group Arch Int Med 2010

Percent () Completing Outcome

Measures at Years 1-4

Intervention Group

(ILI)

Year 1 971

Year 2 949

Year 3 940

Year 4 941

Comparison Group

(DSE)

Year 1 957

Year 2 935

Year 3 938

Year 4 931

Look AHEAD Summary

ILI had significantly greater improvements than DSE in all CVD risk factors averaged across 4 years (except LDL-C)

There may be long-term beneficial effects from this 4-year period in which ILI subjects have been exposed to lower CVD risk factors

Longer follow-ups will determine whether these lowered CVD risk factors can be maintained amp whether lifestyle intervention has positive effects on CVD morbidity amp mortality

Mary J

Female

White

56 years old at start of Look AHEAD

study

Past Medical History Type 2 diabetes

overweight diverticulosis arthritis

sleep apnea back pain

Mary J

bullLong term strugglesbull Helping youngest daughter with

personal issues and children

bull Rotator cuff problems

bull Degenerative disks in back

bull Rheumatoid arthritis

bull Diabetes

bull Physically demanding job

bull Financial struggles

Pounds

Years

82007 grandkids enter pre-school

Catherine L

Female

White

47 years old at start of Look AHEAD

study

Past Medical History Type 2 diabetes

overweight high blood pressure

hypothyroidism back pain

Catherine L

Long term struggles

bull Motherrsquos declining health and death

bull Multiple serious injuries

bull Sudden death of sister

bull Death of step-father

bull Declining economy

bull Children living at home

Pounds

Years

Realistic Management Goals

5-10 weight loss

Health energy and fitness

Well-being and self-esteem

Mood and appearance

Functional and recreational

activity

Key Elements

Focus on health and energy

Food and physical activity diaries

Gradual increase in physical activity

Gradual reduction in dietary fat

No feelings of food deprivation

Social support groups

Recommended Strategies for Building

Sustainable Healthy Communities

Overview from USA

Promote the availability of affordable healthy

food and beverages

Support healthy food and beverage choices

Encourage breastfeeding

Encourage physical activity or limit sedentary

activity among children amp youth

Create safe communities that support physical

activity

Encourage communities to organize for change

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Increase the availability of healthier food and

beverage choices in public service venues (eg

schools city amp county buildings etc)

--Insufficient evidence in school-based programs

--Associations suggest availability amp increased

consumption

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve availability of affordable healthier

food amp beverage choices in public service

venues

--Reducing the cost of healthier foods

increases their purchase

--Providing coupons redeemable for

healthier foods increases their purchase

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve geographic availability of

supermarkets in underserved areas

-- Greater access to nearby supermarkets is

associated with healthier eating behaviors

-- Increasing the number of supermarkets in

underserved neighborhoods increased

real estate values increased economic

activity amp employment amp resulted in lower

food prices

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Provide incentives to food retailers to locate in

andor offer healthier food choices in

underserved areas

-- Presence of retail venues that provide healthier

foods is associated with better nutrition

-- Greater availability of supermarkets was

associated with lower adolescent BMI scores

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Improve availability of mechanisms for

purchasing foods from farms

--Evidence supporting a direct link between

purchasing food from farms amp improved diet is

limited

--Two studies of initiatives to encourage

participation in farmersrsquo market showed

increased intention to eat more fruits amp

vegetables but no direct evidence

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Provide incentives for the production

distribution and procurement of foods from local

farms

--No evidence has been published to link local

food production amp health outcomes

--There is a current study exploring the potential

nutritional amp health benefits of eating locally

grown foods

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Restrict availability of less healthy foods amp

beverages in public service venues

--No peer-reviewed studies examined the impact

designed to restrict availability of less healthy

foods in public service venues

--21 states have policies that restrict the sale of

competitive foods in schools beyond USDA

regulations however no studies have evaluated

the impact of the policies

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Institute smaller portion size options in public

service venues

--Evidence is lacking to demonstrate effectiveness

of population-based interventions aimed at

reducing portion sizes in public service venues

--Evidence from clinical studies in laboratories

demonstrates decreasing portion sizes

decreases energy intake

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Limit advertisements of less healthy foods amp

beverages

--Little evidence is available regarding the impact

of restricting advertising on purchasing amp

consumption of less healthy foods

--Cross-sectional time-series studies of tobacco-

control efforts suggest an association between

advertising bans amp decreased tobacco

consumption

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Discourage consumption of sugar-sweetened

beverages

--One longitudinal study of a school-based

intervention among Native-American high school

students showed a substantial reduction in

sugar-sweetened beverages over a 3-year

period

--A RCT of a home-based intervention that

eliminated sugar-sweetened beverages showed

reduction in BMI scores

Recommended Community Strategies Strategies to encourage breastfeeding

Increase support for breastfeeding

--Evidence directly linking environmental

interventions that support breastfeeding with

obesity-related outcomes is lacking

--Epidemiologic studies indicate that breastfeeding

helps prevent pediatric obesity

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Require physical education in schools

--14 studies have demonstrated that school-based

PE was effective in increasing levels of physical

activity and improving physical fitness

--Minimum of 150 minwk in elementary schools

225 minwk in middle schools and high schools

throughout the school year as recommended by

NASPE

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Increase opportunities for extracurricular

physical activity

--Participation in after-school programs increased

studentsrsquo level of physical activity amp improved

obesity-related outcomes (improved CV fitness

reduced body fat)

--2 pilot studies providing extracurricular physical

activity showed increased levels of PA amp

decreased sedentary behavior

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Reduce screen time in public service venues

--A school-based RCT indicated that children who

reduced their television videotape amp video

game use had significant decrease in BMI tricep

skin fold thickness amp waist circumference

compared to controls

--Spending less time watching television is

associated with increased physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Improve access to outdoor recreational

facilities

--Review of 108 studies indicated that access to facilities

and programs for recreation near their homes amp time

spent outdoors correlated positively with increased

physical activity among childrenamp adults

--Perceptions that footpaths are safe for walking was

significantly associated with adults being classified as

physically active at a level sufficient for health benefits

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting

bicycling

--Longitudinal intervention studies have

demonstrated that improving bicycling

infrastructure is associated with increased

frequency of bicycling

--Cross-sectional studies indicated a significant

association between bicycling infrastructure amp

frequency of biking

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting walking

--Reviews of cross-sectional studies of

environmental correlates of physical activity amp

walking generally find a positive association

between infrastructure supportive of walking amp

physical activity

--Identifying amp creating safe routes to school

together with educational components

increased the number of students walking to

school

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Locating schools within easy walking

distance of residential areas

--Community-scale urban design amp land use policies amp

practices including locating schools stores workplaces

amp recreation areas close to residential areas are

effective in facilitating an increase in levels of physical

activity

--Majority of efforts to encourage walking to school involve

improving the routes rather than improving the location

of schools

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Improve access to public transportation

--Insufficient evidence exists to determine

effectiveness of transportation policies in

increasing the level of physical activity or

improving fitness

--1 study indicated that 29 of individuals who

walk to and from public transit achieve at least

30 minutes of daily physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Zone for mixed-use development

--Allows residential commercial institutional amp

other public land uses to be located in close

proximity to one another

--Studies using correlation analyses amp regression

models indicated that mixed land use was

associated with increased walking amp cycling

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance personal safety in areas where

persons are or could be physically active

--Cross-sectional studies have demonstrated a

negative relationship between crime rates andor

perceived safety amp physical activity in

neighborhoods

--Few intervention studies have evaluated the

impact of policies amp practices to improve

personal safety on physical activity

Geospatial Mapping Linking Urban

Environments to Health Risk

Measure association between environmental variables amp health risk factors

Assess relationships between variables at different levels of analysis

Used in conjunction with linear analyses

Our Community Environmental Model

of Obesity

Community Factors

Poverty

Crime

Grocery Quality

Restaurants

Parks

Sidewalks

Fast Food Outlets

Recreational

Facilities

Individual Factors

Dietary Intake

Physical Activity

Genetics

Family History

StressCoping

Eating Disorders

Psychological

Problems

Weight

Status

Chosen Neighborhoods

Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped

We then matched census-block groups within the income groups by population density and percentage of minority representation

One matched block group per income level was randomly selected

Prevalence of Obesity in

Block-Groups

0

5

10

15

20

25

30

35

40

45

50

Ag

e-a

dju

sted

Ob

esit

y P

rev

ale

nce

(

)

High-Income Low-Income

Age-standardized to the 1990 US Census

Density of Environmental Factors in the

Community Contributes to a ldquoToxicrdquo

Obesity Environment

0

2

4

6

8

10

12

14

16

18

Fast-food Convenience Store Bars

Den

sity

10

00

perso

ns

High-Income Low-Income

COMMUNITYrsquoS PERCEPTION OF SAFETY

0

5

10

15

20

25

30

35

40

Daytime Nighttime

Perc

en

t (

) F

eeli

ng

So

mew

hat

Safe

or

Un

safe

Low-Income High-Income

Percent Substandard (or worse) Housing

or Ground Conditions

of Residential Properties

0

10

20

30

Structural Grounds

Perc

en

t (

)

Low-Income High-Income

CONCLUSIONS

These data suggest that the higher

frequency of outlets providing

calorically-dense foods and alcohol may

contribute to greater obesity prevalence

in residents of low-income communities

More research is needed to thoroughly

document environmental determinants

of health and obesity

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

From 1994-1998 HUD randomly assigned

4498 women with children living in public

housing in high-poverty urban census

tracts to one of three groups (1) housing

vouchers redeemable only if they moved

to a low-poverty census tract (2)

unrestricted vouchers or (3) control group

(no vouchers)

Ludwig et al NEJM 201136516

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

10-12 year follow-up showed modest but

potentially important reductions in the

prevalence of extreme obesity amp diabetes in the

group moving from a neighborhood with high

poverty on one of low poverty compared to the

control group

No differences between the group receiving

traditional vouchers amp the control group

ldquoNeighborhoods matterrdquo

Ludwig et al NEJM 201136516

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance traffic safety in areas where

persons are or could be physically active

--Community-scale urban design amp land use policies to

promote physical activity including design components

to improve street lighting infrastructure projects to

increase safety of pedestrian street crossing and use of

traffic calming approaches such as speed humps amp

traffic circles are effective in increasing physical activity

--Both community-scale amp street-scale policies amp practices

are effective in increasing physical activity

Recommended Community Strategies Encourage Communities to Organize for Change

Participate in community coalitions or

partnerships to address obesity

--Little evidence is available to determine the

impact of community coalitions on obesity

prevention

--The presence of anti-smoking community

coalitions has been associated with lower rates

of tobacco consumption

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

$103 million awarded to 61 states and

communities including state amp local government

agencies tribes amp territories amp state amp local non-

profit organizations

To build capacity to implement changes for

community prevention efforts to ensure long-

term success

To implement evidence-based and practice-

based programs to improve health amp wellness

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Priority areas are

Tobacco-free living

Active living and healthy eating

Evidence-based quality clinical and other

preventive health services for prevention

and control of high blood pressure and

high cholesterol

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Applicants proposed specific activities in

line with their chosen priority areas in their

applications

Grantee activities will not be finalized until

plans are negotiated with CDC by early

2012

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Capacity-Building Award

The Confederated Tribes of The Chehalis

Reservation is receiving a $498663 planning

award to build capacity to support healthy

lifestyles among their tribal population of 1500

in Washington State

Work will target tobacco-free living active living

and healthy eating and quality clinical and other

healthy serviceswwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Implementation Award

Austin TX Dept of Health and Human Services

is receiving $1026158 to serve Travis County

(Austin) to expand efforts in tobacco-free living

active living and healthy eating quality clinical

and other preventive services social and

emotional wellness and healthy and safe

physical environmentswwwcdcgov1052011

Building sustainable healthy

communities Bottom line

Obesity is an environmental problem

Despite progress in genetic research public health advances only will occur when we take the environment seriously

Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment

Until we do this we will not make substantial progress in addressing the epidemic of obesity

Poston amp Foreyt Atherosclerosis 1999

Whatrsquos the best approach

Integrate all sectors of society into community

change interventions

Incorporate

Science amp Technology

Education

FamilyCommunity

Healthcare

Arts amp Entertainment

Law amp Politics

Commerce amp Trade

Sectors of Society

Arts amp Entertainm

ent

Commerce amp Trade

Education

FamilyCommunity

Healthcare

Law amp Politics

Science amp Technology

Project FIT rationale design and baseline characteristics of a school- and community-

based intervention to address physical activity and healthy eating among low-income

elementary school children

Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D

Oh HJ Orth J Randall S Mayfield K Holmes D

Source

Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu

Abstract

BACKGROUND

This paper describes Project FIT a collaboration between the public school system local

health systems physicians neighborhood associations businesses faith-based leaders

community agencies and university researchers to develop a multi-faceted approach to

promote physical activity and healthy eating toward the general goal of preventing and

reducing childhood obesity among children in Grand Rapids MI USA

METHODSDESIGN

There are four overall components to Project FIT school community social marketing and

school staff wellness - all that focus on 1) increasing access to safe and affordable physical

activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)

improving the affordability and availability of nutritious food in the neighborhoods surrounding

the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding

nutrition and physical activity among school staff parents and students 4) impacting the

culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging

dialogue among all community partners to leverage existing programs and introduce new

ones

Look AHEAD

Study Interventions

bull Diabetes support and education - DSE (control group)

bull Lifestyle intervention ndash ILI (treatment group)

Look AHEAD

Lifestyle Intervention

Goals

bull 7 weight loss for the group (10

for individual)

bull 175 minutes of moderate intensity

activity

Look AHEAD

Lifestyle Intervention

bull Diet

ndash ADA NCEP (lt 30 fat lt 10 sat fat

gt15 protein)

ndash 1200-1500 (if weight lt250lbs)

ndash 1500-1800 (if weight gt250lbs)

ndash During first 4 weeks to 4 months portion

control (liquid meal replacements or

structured meal plan)

Look AHEAD

Lifestyle Intervention

bull Physical Activity

ndash unsupervised

ndash 175 minutes moderate intensityweek

ndash 5 daysweek

ndash walking

Weight Loss at 1-Year

-9

ILI 0

-1

-2

-3

-4

-5

-6

-7

-8

DSE

p lt 00001

W

eig

ht

Chan

ge

86

07

The Look AHEAD Research Group Diabetes Care 2007

Reduction in Initial Weight by Gender

N=872

N=1229N=1197

N=830

-12

-10

-8

-6

-4

-2

0

0 2 4 6 8 10 12

Months

R

ed

uctio

n in

In

itia

l W

eig

ht

Men

Women

Plt0001

The Look AHEAD Research Group Diabetes Care 2007

Fitness Change () at 1-Year

0

5

10

15

20

25

Mean

Fitness C

hange

Unadjusted

Plt0001Adjusted for 1 Year

Weight Change Plt0001

58

209

108

159

DSE ILI ILIDSE

The Look AHEAD Research Group Diabetes Care 2007

1-Year Changes in Markers of

Diabetes Control

Markers of Diabetes

Control ILI DSE P-value

Hemoglobin A1c () BL

Hemoglobin A1c () Y1

Y1 ndash Baseline

725

661

-064

729

715

-014

026

lt0001

lt0001

Fasting glucose (mgdl) BL

Fasting glucose (mgdl) Y1

Y1 ndash Baseline

1519

1304

-215

1536

1464

-72

021

lt0001

lt0001

Diabetes medications BL

Diabetes medications Y1

Y1 ndash Baseline

865

786

-78

865

887

22

093

lt0001

lt0001

1-Year Changes in Markers of

Blood Pressure ControlMarkers of Blood Pressure

Control ILI DSE P-value

Systolic BP (mmHg) BL

Systolic BP (mmHg) Y1

Y1 ndash Baseline

1282

1214

-68

1294

1266

-28

026

lt0001

lt0001

Diastolic BP (mmHg) BL

Diastolic BP (mmHg) Y1

Y1 ndash Baseline

699

670

-30

704

686

-18

011

lt0001

lt0001

Antihypertensive medications BL

Antihypertensive medications Y1

Y1 ndash Baseline

753

752

-01

737

759

22

023

054

002

1-Year Changes in Markers of Lipid

Control

Markers of Lipid Control ILI DSE P-value

LDL-cholesterol (mgdl) BL

LDL-cholesterol (mgdl) Y1

Y1 ndash Baseline

1122

1070

-52

1124

1067

-57

078

074

049

HDL-cholesterol (mgdl) BL

HDL-cholesterol (mgdl) Y1

Y1 ndash Baseline

435

469

34

436

449

14

080

lt0001

lt0001

Triglycerides (mgdl) BL

Triglycerides (mgdl) Y1

Y1 ndash Baseline

1828

1525

-303

1800

1654

-146

038

lt0001

lt0001

Lipid lowering medications BL

Lipid lowering medications Y1

Y1 ndash Baseline

494

530

37

484

578

94

052

lt0001

lt0001

1-Year Changes in Percent of Participants

Meeting ADA Goals

ADA Goal ILI DSE P-value

Hemoglobin A1c lt 7 BL

Hemoglobin A1c lt 7 Y1

Y1 ndash Baseline

463

727

264

454

508

54

050

lt0001

lt0001

Blood pressure lt 13080 mmHg BL

Blood pressure lt 13080 mmHg Y1

Y1 ndash Baseline

535

686

151

499

570

70

001

lt0001

lt0001

LDL-cholesterol lt 100 mgdl BL

LDL-cholesterol lt 100 mgdl Y1

Y1 ndash Baseline

371

438

67

369

449

80

087

045

034

All three goals BL

All three goals Y1

Y1 ndash Baseline

108

236

128

95

160

65

013

lt0001

lt0001

Mean Changes in Weight Fitness amp BP

Averaged Over Four Years

DSE

Mean

ILI

Mean

P-value

Weight Loss

( initial wt)

-088 -615 lt 00001

Fitness

( METS)

196 1274 lt00001

HbA1c -009 -036 lt 00001

SBP (mm Hg) -297 -533 lt 00001

DBP (mm Hg) -248 -292 0012

Look AHEAD Research Group Arch Int Med 2010

Mean Changes in Lipid Profile

Averaged Over Four Years

DSE

Mean

ILI

Mean

P-value

HDL (mgdl) 197 367 lt00001

TG (mgdl) -1975 -2556 00006

LDL (mgdl) -1284 -1127 0009

LDL (mgdl)

(Adjusting for

medication use)

-922 -875 042

Look AHEAD Research Group Arch Int Med 2010

Percent () Completing Outcome

Measures at Years 1-4

Intervention Group

(ILI)

Year 1 971

Year 2 949

Year 3 940

Year 4 941

Comparison Group

(DSE)

Year 1 957

Year 2 935

Year 3 938

Year 4 931

Look AHEAD Summary

ILI had significantly greater improvements than DSE in all CVD risk factors averaged across 4 years (except LDL-C)

There may be long-term beneficial effects from this 4-year period in which ILI subjects have been exposed to lower CVD risk factors

Longer follow-ups will determine whether these lowered CVD risk factors can be maintained amp whether lifestyle intervention has positive effects on CVD morbidity amp mortality

Mary J

Female

White

56 years old at start of Look AHEAD

study

Past Medical History Type 2 diabetes

overweight diverticulosis arthritis

sleep apnea back pain

Mary J

bullLong term strugglesbull Helping youngest daughter with

personal issues and children

bull Rotator cuff problems

bull Degenerative disks in back

bull Rheumatoid arthritis

bull Diabetes

bull Physically demanding job

bull Financial struggles

Pounds

Years

82007 grandkids enter pre-school

Catherine L

Female

White

47 years old at start of Look AHEAD

study

Past Medical History Type 2 diabetes

overweight high blood pressure

hypothyroidism back pain

Catherine L

Long term struggles

bull Motherrsquos declining health and death

bull Multiple serious injuries

bull Sudden death of sister

bull Death of step-father

bull Declining economy

bull Children living at home

Pounds

Years

Realistic Management Goals

5-10 weight loss

Health energy and fitness

Well-being and self-esteem

Mood and appearance

Functional and recreational

activity

Key Elements

Focus on health and energy

Food and physical activity diaries

Gradual increase in physical activity

Gradual reduction in dietary fat

No feelings of food deprivation

Social support groups

Recommended Strategies for Building

Sustainable Healthy Communities

Overview from USA

Promote the availability of affordable healthy

food and beverages

Support healthy food and beverage choices

Encourage breastfeeding

Encourage physical activity or limit sedentary

activity among children amp youth

Create safe communities that support physical

activity

Encourage communities to organize for change

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Increase the availability of healthier food and

beverage choices in public service venues (eg

schools city amp county buildings etc)

--Insufficient evidence in school-based programs

--Associations suggest availability amp increased

consumption

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve availability of affordable healthier

food amp beverage choices in public service

venues

--Reducing the cost of healthier foods

increases their purchase

--Providing coupons redeemable for

healthier foods increases their purchase

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve geographic availability of

supermarkets in underserved areas

-- Greater access to nearby supermarkets is

associated with healthier eating behaviors

-- Increasing the number of supermarkets in

underserved neighborhoods increased

real estate values increased economic

activity amp employment amp resulted in lower

food prices

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Provide incentives to food retailers to locate in

andor offer healthier food choices in

underserved areas

-- Presence of retail venues that provide healthier

foods is associated with better nutrition

-- Greater availability of supermarkets was

associated with lower adolescent BMI scores

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Improve availability of mechanisms for

purchasing foods from farms

--Evidence supporting a direct link between

purchasing food from farms amp improved diet is

limited

--Two studies of initiatives to encourage

participation in farmersrsquo market showed

increased intention to eat more fruits amp

vegetables but no direct evidence

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Provide incentives for the production

distribution and procurement of foods from local

farms

--No evidence has been published to link local

food production amp health outcomes

--There is a current study exploring the potential

nutritional amp health benefits of eating locally

grown foods

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Restrict availability of less healthy foods amp

beverages in public service venues

--No peer-reviewed studies examined the impact

designed to restrict availability of less healthy

foods in public service venues

--21 states have policies that restrict the sale of

competitive foods in schools beyond USDA

regulations however no studies have evaluated

the impact of the policies

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Institute smaller portion size options in public

service venues

--Evidence is lacking to demonstrate effectiveness

of population-based interventions aimed at

reducing portion sizes in public service venues

--Evidence from clinical studies in laboratories

demonstrates decreasing portion sizes

decreases energy intake

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Limit advertisements of less healthy foods amp

beverages

--Little evidence is available regarding the impact

of restricting advertising on purchasing amp

consumption of less healthy foods

--Cross-sectional time-series studies of tobacco-

control efforts suggest an association between

advertising bans amp decreased tobacco

consumption

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Discourage consumption of sugar-sweetened

beverages

--One longitudinal study of a school-based

intervention among Native-American high school

students showed a substantial reduction in

sugar-sweetened beverages over a 3-year

period

--A RCT of a home-based intervention that

eliminated sugar-sweetened beverages showed

reduction in BMI scores

Recommended Community Strategies Strategies to encourage breastfeeding

Increase support for breastfeeding

--Evidence directly linking environmental

interventions that support breastfeeding with

obesity-related outcomes is lacking

--Epidemiologic studies indicate that breastfeeding

helps prevent pediatric obesity

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Require physical education in schools

--14 studies have demonstrated that school-based

PE was effective in increasing levels of physical

activity and improving physical fitness

--Minimum of 150 minwk in elementary schools

225 minwk in middle schools and high schools

throughout the school year as recommended by

NASPE

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Increase opportunities for extracurricular

physical activity

--Participation in after-school programs increased

studentsrsquo level of physical activity amp improved

obesity-related outcomes (improved CV fitness

reduced body fat)

--2 pilot studies providing extracurricular physical

activity showed increased levels of PA amp

decreased sedentary behavior

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Reduce screen time in public service venues

--A school-based RCT indicated that children who

reduced their television videotape amp video

game use had significant decrease in BMI tricep

skin fold thickness amp waist circumference

compared to controls

--Spending less time watching television is

associated with increased physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Improve access to outdoor recreational

facilities

--Review of 108 studies indicated that access to facilities

and programs for recreation near their homes amp time

spent outdoors correlated positively with increased

physical activity among childrenamp adults

--Perceptions that footpaths are safe for walking was

significantly associated with adults being classified as

physically active at a level sufficient for health benefits

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting

bicycling

--Longitudinal intervention studies have

demonstrated that improving bicycling

infrastructure is associated with increased

frequency of bicycling

--Cross-sectional studies indicated a significant

association between bicycling infrastructure amp

frequency of biking

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting walking

--Reviews of cross-sectional studies of

environmental correlates of physical activity amp

walking generally find a positive association

between infrastructure supportive of walking amp

physical activity

--Identifying amp creating safe routes to school

together with educational components

increased the number of students walking to

school

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Locating schools within easy walking

distance of residential areas

--Community-scale urban design amp land use policies amp

practices including locating schools stores workplaces

amp recreation areas close to residential areas are

effective in facilitating an increase in levels of physical

activity

--Majority of efforts to encourage walking to school involve

improving the routes rather than improving the location

of schools

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Improve access to public transportation

--Insufficient evidence exists to determine

effectiveness of transportation policies in

increasing the level of physical activity or

improving fitness

--1 study indicated that 29 of individuals who

walk to and from public transit achieve at least

30 minutes of daily physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Zone for mixed-use development

--Allows residential commercial institutional amp

other public land uses to be located in close

proximity to one another

--Studies using correlation analyses amp regression

models indicated that mixed land use was

associated with increased walking amp cycling

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance personal safety in areas where

persons are or could be physically active

--Cross-sectional studies have demonstrated a

negative relationship between crime rates andor

perceived safety amp physical activity in

neighborhoods

--Few intervention studies have evaluated the

impact of policies amp practices to improve

personal safety on physical activity

Geospatial Mapping Linking Urban

Environments to Health Risk

Measure association between environmental variables amp health risk factors

Assess relationships between variables at different levels of analysis

Used in conjunction with linear analyses

Our Community Environmental Model

of Obesity

Community Factors

Poverty

Crime

Grocery Quality

Restaurants

Parks

Sidewalks

Fast Food Outlets

Recreational

Facilities

Individual Factors

Dietary Intake

Physical Activity

Genetics

Family History

StressCoping

Eating Disorders

Psychological

Problems

Weight

Status

Chosen Neighborhoods

Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped

We then matched census-block groups within the income groups by population density and percentage of minority representation

One matched block group per income level was randomly selected

Prevalence of Obesity in

Block-Groups

0

5

10

15

20

25

30

35

40

45

50

Ag

e-a

dju

sted

Ob

esit

y P

rev

ale

nce

(

)

High-Income Low-Income

Age-standardized to the 1990 US Census

Density of Environmental Factors in the

Community Contributes to a ldquoToxicrdquo

Obesity Environment

0

2

4

6

8

10

12

14

16

18

Fast-food Convenience Store Bars

Den

sity

10

00

perso

ns

High-Income Low-Income

COMMUNITYrsquoS PERCEPTION OF SAFETY

0

5

10

15

20

25

30

35

40

Daytime Nighttime

Perc

en

t (

) F

eeli

ng

So

mew

hat

Safe

or

Un

safe

Low-Income High-Income

Percent Substandard (or worse) Housing

or Ground Conditions

of Residential Properties

0

10

20

30

Structural Grounds

Perc

en

t (

)

Low-Income High-Income

CONCLUSIONS

These data suggest that the higher

frequency of outlets providing

calorically-dense foods and alcohol may

contribute to greater obesity prevalence

in residents of low-income communities

More research is needed to thoroughly

document environmental determinants

of health and obesity

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

From 1994-1998 HUD randomly assigned

4498 women with children living in public

housing in high-poverty urban census

tracts to one of three groups (1) housing

vouchers redeemable only if they moved

to a low-poverty census tract (2)

unrestricted vouchers or (3) control group

(no vouchers)

Ludwig et al NEJM 201136516

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

10-12 year follow-up showed modest but

potentially important reductions in the

prevalence of extreme obesity amp diabetes in the

group moving from a neighborhood with high

poverty on one of low poverty compared to the

control group

No differences between the group receiving

traditional vouchers amp the control group

ldquoNeighborhoods matterrdquo

Ludwig et al NEJM 201136516

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance traffic safety in areas where

persons are or could be physically active

--Community-scale urban design amp land use policies to

promote physical activity including design components

to improve street lighting infrastructure projects to

increase safety of pedestrian street crossing and use of

traffic calming approaches such as speed humps amp

traffic circles are effective in increasing physical activity

--Both community-scale amp street-scale policies amp practices

are effective in increasing physical activity

Recommended Community Strategies Encourage Communities to Organize for Change

Participate in community coalitions or

partnerships to address obesity

--Little evidence is available to determine the

impact of community coalitions on obesity

prevention

--The presence of anti-smoking community

coalitions has been associated with lower rates

of tobacco consumption

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

$103 million awarded to 61 states and

communities including state amp local government

agencies tribes amp territories amp state amp local non-

profit organizations

To build capacity to implement changes for

community prevention efforts to ensure long-

term success

To implement evidence-based and practice-

based programs to improve health amp wellness

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Priority areas are

Tobacco-free living

Active living and healthy eating

Evidence-based quality clinical and other

preventive health services for prevention

and control of high blood pressure and

high cholesterol

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Applicants proposed specific activities in

line with their chosen priority areas in their

applications

Grantee activities will not be finalized until

plans are negotiated with CDC by early

2012

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Capacity-Building Award

The Confederated Tribes of The Chehalis

Reservation is receiving a $498663 planning

award to build capacity to support healthy

lifestyles among their tribal population of 1500

in Washington State

Work will target tobacco-free living active living

and healthy eating and quality clinical and other

healthy serviceswwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Implementation Award

Austin TX Dept of Health and Human Services

is receiving $1026158 to serve Travis County

(Austin) to expand efforts in tobacco-free living

active living and healthy eating quality clinical

and other preventive services social and

emotional wellness and healthy and safe

physical environmentswwwcdcgov1052011

Building sustainable healthy

communities Bottom line

Obesity is an environmental problem

Despite progress in genetic research public health advances only will occur when we take the environment seriously

Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment

Until we do this we will not make substantial progress in addressing the epidemic of obesity

Poston amp Foreyt Atherosclerosis 1999

Whatrsquos the best approach

Integrate all sectors of society into community

change interventions

Incorporate

Science amp Technology

Education

FamilyCommunity

Healthcare

Arts amp Entertainment

Law amp Politics

Commerce amp Trade

Sectors of Society

Arts amp Entertainm

ent

Commerce amp Trade

Education

FamilyCommunity

Healthcare

Law amp Politics

Science amp Technology

Project FIT rationale design and baseline characteristics of a school- and community-

based intervention to address physical activity and healthy eating among low-income

elementary school children

Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D

Oh HJ Orth J Randall S Mayfield K Holmes D

Source

Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu

Abstract

BACKGROUND

This paper describes Project FIT a collaboration between the public school system local

health systems physicians neighborhood associations businesses faith-based leaders

community agencies and university researchers to develop a multi-faceted approach to

promote physical activity and healthy eating toward the general goal of preventing and

reducing childhood obesity among children in Grand Rapids MI USA

METHODSDESIGN

There are four overall components to Project FIT school community social marketing and

school staff wellness - all that focus on 1) increasing access to safe and affordable physical

activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)

improving the affordability and availability of nutritious food in the neighborhoods surrounding

the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding

nutrition and physical activity among school staff parents and students 4) impacting the

culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging

dialogue among all community partners to leverage existing programs and introduce new

ones

Look AHEAD

Lifestyle Intervention

Goals

bull 7 weight loss for the group (10

for individual)

bull 175 minutes of moderate intensity

activity

Look AHEAD

Lifestyle Intervention

bull Diet

ndash ADA NCEP (lt 30 fat lt 10 sat fat

gt15 protein)

ndash 1200-1500 (if weight lt250lbs)

ndash 1500-1800 (if weight gt250lbs)

ndash During first 4 weeks to 4 months portion

control (liquid meal replacements or

structured meal plan)

Look AHEAD

Lifestyle Intervention

bull Physical Activity

ndash unsupervised

ndash 175 minutes moderate intensityweek

ndash 5 daysweek

ndash walking

Weight Loss at 1-Year

-9

ILI 0

-1

-2

-3

-4

-5

-6

-7

-8

DSE

p lt 00001

W

eig

ht

Chan

ge

86

07

The Look AHEAD Research Group Diabetes Care 2007

Reduction in Initial Weight by Gender

N=872

N=1229N=1197

N=830

-12

-10

-8

-6

-4

-2

0

0 2 4 6 8 10 12

Months

R

ed

uctio

n in

In

itia

l W

eig

ht

Men

Women

Plt0001

The Look AHEAD Research Group Diabetes Care 2007

Fitness Change () at 1-Year

0

5

10

15

20

25

Mean

Fitness C

hange

Unadjusted

Plt0001Adjusted for 1 Year

Weight Change Plt0001

58

209

108

159

DSE ILI ILIDSE

The Look AHEAD Research Group Diabetes Care 2007

1-Year Changes in Markers of

Diabetes Control

Markers of Diabetes

Control ILI DSE P-value

Hemoglobin A1c () BL

Hemoglobin A1c () Y1

Y1 ndash Baseline

725

661

-064

729

715

-014

026

lt0001

lt0001

Fasting glucose (mgdl) BL

Fasting glucose (mgdl) Y1

Y1 ndash Baseline

1519

1304

-215

1536

1464

-72

021

lt0001

lt0001

Diabetes medications BL

Diabetes medications Y1

Y1 ndash Baseline

865

786

-78

865

887

22

093

lt0001

lt0001

1-Year Changes in Markers of

Blood Pressure ControlMarkers of Blood Pressure

Control ILI DSE P-value

Systolic BP (mmHg) BL

Systolic BP (mmHg) Y1

Y1 ndash Baseline

1282

1214

-68

1294

1266

-28

026

lt0001

lt0001

Diastolic BP (mmHg) BL

Diastolic BP (mmHg) Y1

Y1 ndash Baseline

699

670

-30

704

686

-18

011

lt0001

lt0001

Antihypertensive medications BL

Antihypertensive medications Y1

Y1 ndash Baseline

753

752

-01

737

759

22

023

054

002

1-Year Changes in Markers of Lipid

Control

Markers of Lipid Control ILI DSE P-value

LDL-cholesterol (mgdl) BL

LDL-cholesterol (mgdl) Y1

Y1 ndash Baseline

1122

1070

-52

1124

1067

-57

078

074

049

HDL-cholesterol (mgdl) BL

HDL-cholesterol (mgdl) Y1

Y1 ndash Baseline

435

469

34

436

449

14

080

lt0001

lt0001

Triglycerides (mgdl) BL

Triglycerides (mgdl) Y1

Y1 ndash Baseline

1828

1525

-303

1800

1654

-146

038

lt0001

lt0001

Lipid lowering medications BL

Lipid lowering medications Y1

Y1 ndash Baseline

494

530

37

484

578

94

052

lt0001

lt0001

1-Year Changes in Percent of Participants

Meeting ADA Goals

ADA Goal ILI DSE P-value

Hemoglobin A1c lt 7 BL

Hemoglobin A1c lt 7 Y1

Y1 ndash Baseline

463

727

264

454

508

54

050

lt0001

lt0001

Blood pressure lt 13080 mmHg BL

Blood pressure lt 13080 mmHg Y1

Y1 ndash Baseline

535

686

151

499

570

70

001

lt0001

lt0001

LDL-cholesterol lt 100 mgdl BL

LDL-cholesterol lt 100 mgdl Y1

Y1 ndash Baseline

371

438

67

369

449

80

087

045

034

All three goals BL

All three goals Y1

Y1 ndash Baseline

108

236

128

95

160

65

013

lt0001

lt0001

Mean Changes in Weight Fitness amp BP

Averaged Over Four Years

DSE

Mean

ILI

Mean

P-value

Weight Loss

( initial wt)

-088 -615 lt 00001

Fitness

( METS)

196 1274 lt00001

HbA1c -009 -036 lt 00001

SBP (mm Hg) -297 -533 lt 00001

DBP (mm Hg) -248 -292 0012

Look AHEAD Research Group Arch Int Med 2010

Mean Changes in Lipid Profile

Averaged Over Four Years

DSE

Mean

ILI

Mean

P-value

HDL (mgdl) 197 367 lt00001

TG (mgdl) -1975 -2556 00006

LDL (mgdl) -1284 -1127 0009

LDL (mgdl)

(Adjusting for

medication use)

-922 -875 042

Look AHEAD Research Group Arch Int Med 2010

Percent () Completing Outcome

Measures at Years 1-4

Intervention Group

(ILI)

Year 1 971

Year 2 949

Year 3 940

Year 4 941

Comparison Group

(DSE)

Year 1 957

Year 2 935

Year 3 938

Year 4 931

Look AHEAD Summary

ILI had significantly greater improvements than DSE in all CVD risk factors averaged across 4 years (except LDL-C)

There may be long-term beneficial effects from this 4-year period in which ILI subjects have been exposed to lower CVD risk factors

Longer follow-ups will determine whether these lowered CVD risk factors can be maintained amp whether lifestyle intervention has positive effects on CVD morbidity amp mortality

Mary J

Female

White

56 years old at start of Look AHEAD

study

Past Medical History Type 2 diabetes

overweight diverticulosis arthritis

sleep apnea back pain

Mary J

bullLong term strugglesbull Helping youngest daughter with

personal issues and children

bull Rotator cuff problems

bull Degenerative disks in back

bull Rheumatoid arthritis

bull Diabetes

bull Physically demanding job

bull Financial struggles

Pounds

Years

82007 grandkids enter pre-school

Catherine L

Female

White

47 years old at start of Look AHEAD

study

Past Medical History Type 2 diabetes

overweight high blood pressure

hypothyroidism back pain

Catherine L

Long term struggles

bull Motherrsquos declining health and death

bull Multiple serious injuries

bull Sudden death of sister

bull Death of step-father

bull Declining economy

bull Children living at home

Pounds

Years

Realistic Management Goals

5-10 weight loss

Health energy and fitness

Well-being and self-esteem

Mood and appearance

Functional and recreational

activity

Key Elements

Focus on health and energy

Food and physical activity diaries

Gradual increase in physical activity

Gradual reduction in dietary fat

No feelings of food deprivation

Social support groups

Recommended Strategies for Building

Sustainable Healthy Communities

Overview from USA

Promote the availability of affordable healthy

food and beverages

Support healthy food and beverage choices

Encourage breastfeeding

Encourage physical activity or limit sedentary

activity among children amp youth

Create safe communities that support physical

activity

Encourage communities to organize for change

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Increase the availability of healthier food and

beverage choices in public service venues (eg

schools city amp county buildings etc)

--Insufficient evidence in school-based programs

--Associations suggest availability amp increased

consumption

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve availability of affordable healthier

food amp beverage choices in public service

venues

--Reducing the cost of healthier foods

increases their purchase

--Providing coupons redeemable for

healthier foods increases their purchase

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve geographic availability of

supermarkets in underserved areas

-- Greater access to nearby supermarkets is

associated with healthier eating behaviors

-- Increasing the number of supermarkets in

underserved neighborhoods increased

real estate values increased economic

activity amp employment amp resulted in lower

food prices

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Provide incentives to food retailers to locate in

andor offer healthier food choices in

underserved areas

-- Presence of retail venues that provide healthier

foods is associated with better nutrition

-- Greater availability of supermarkets was

associated with lower adolescent BMI scores

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Improve availability of mechanisms for

purchasing foods from farms

--Evidence supporting a direct link between

purchasing food from farms amp improved diet is

limited

--Two studies of initiatives to encourage

participation in farmersrsquo market showed

increased intention to eat more fruits amp

vegetables but no direct evidence

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Provide incentives for the production

distribution and procurement of foods from local

farms

--No evidence has been published to link local

food production amp health outcomes

--There is a current study exploring the potential

nutritional amp health benefits of eating locally

grown foods

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Restrict availability of less healthy foods amp

beverages in public service venues

--No peer-reviewed studies examined the impact

designed to restrict availability of less healthy

foods in public service venues

--21 states have policies that restrict the sale of

competitive foods in schools beyond USDA

regulations however no studies have evaluated

the impact of the policies

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Institute smaller portion size options in public

service venues

--Evidence is lacking to demonstrate effectiveness

of population-based interventions aimed at

reducing portion sizes in public service venues

--Evidence from clinical studies in laboratories

demonstrates decreasing portion sizes

decreases energy intake

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Limit advertisements of less healthy foods amp

beverages

--Little evidence is available regarding the impact

of restricting advertising on purchasing amp

consumption of less healthy foods

--Cross-sectional time-series studies of tobacco-

control efforts suggest an association between

advertising bans amp decreased tobacco

consumption

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Discourage consumption of sugar-sweetened

beverages

--One longitudinal study of a school-based

intervention among Native-American high school

students showed a substantial reduction in

sugar-sweetened beverages over a 3-year

period

--A RCT of a home-based intervention that

eliminated sugar-sweetened beverages showed

reduction in BMI scores

Recommended Community Strategies Strategies to encourage breastfeeding

Increase support for breastfeeding

--Evidence directly linking environmental

interventions that support breastfeeding with

obesity-related outcomes is lacking

--Epidemiologic studies indicate that breastfeeding

helps prevent pediatric obesity

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Require physical education in schools

--14 studies have demonstrated that school-based

PE was effective in increasing levels of physical

activity and improving physical fitness

--Minimum of 150 minwk in elementary schools

225 minwk in middle schools and high schools

throughout the school year as recommended by

NASPE

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Increase opportunities for extracurricular

physical activity

--Participation in after-school programs increased

studentsrsquo level of physical activity amp improved

obesity-related outcomes (improved CV fitness

reduced body fat)

--2 pilot studies providing extracurricular physical

activity showed increased levels of PA amp

decreased sedentary behavior

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Reduce screen time in public service venues

--A school-based RCT indicated that children who

reduced their television videotape amp video

game use had significant decrease in BMI tricep

skin fold thickness amp waist circumference

compared to controls

--Spending less time watching television is

associated with increased physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Improve access to outdoor recreational

facilities

--Review of 108 studies indicated that access to facilities

and programs for recreation near their homes amp time

spent outdoors correlated positively with increased

physical activity among childrenamp adults

--Perceptions that footpaths are safe for walking was

significantly associated with adults being classified as

physically active at a level sufficient for health benefits

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting

bicycling

--Longitudinal intervention studies have

demonstrated that improving bicycling

infrastructure is associated with increased

frequency of bicycling

--Cross-sectional studies indicated a significant

association between bicycling infrastructure amp

frequency of biking

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting walking

--Reviews of cross-sectional studies of

environmental correlates of physical activity amp

walking generally find a positive association

between infrastructure supportive of walking amp

physical activity

--Identifying amp creating safe routes to school

together with educational components

increased the number of students walking to

school

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Locating schools within easy walking

distance of residential areas

--Community-scale urban design amp land use policies amp

practices including locating schools stores workplaces

amp recreation areas close to residential areas are

effective in facilitating an increase in levels of physical

activity

--Majority of efforts to encourage walking to school involve

improving the routes rather than improving the location

of schools

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Improve access to public transportation

--Insufficient evidence exists to determine

effectiveness of transportation policies in

increasing the level of physical activity or

improving fitness

--1 study indicated that 29 of individuals who

walk to and from public transit achieve at least

30 minutes of daily physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Zone for mixed-use development

--Allows residential commercial institutional amp

other public land uses to be located in close

proximity to one another

--Studies using correlation analyses amp regression

models indicated that mixed land use was

associated with increased walking amp cycling

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance personal safety in areas where

persons are or could be physically active

--Cross-sectional studies have demonstrated a

negative relationship between crime rates andor

perceived safety amp physical activity in

neighborhoods

--Few intervention studies have evaluated the

impact of policies amp practices to improve

personal safety on physical activity

Geospatial Mapping Linking Urban

Environments to Health Risk

Measure association between environmental variables amp health risk factors

Assess relationships between variables at different levels of analysis

Used in conjunction with linear analyses

Our Community Environmental Model

of Obesity

Community Factors

Poverty

Crime

Grocery Quality

Restaurants

Parks

Sidewalks

Fast Food Outlets

Recreational

Facilities

Individual Factors

Dietary Intake

Physical Activity

Genetics

Family History

StressCoping

Eating Disorders

Psychological

Problems

Weight

Status

Chosen Neighborhoods

Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped

We then matched census-block groups within the income groups by population density and percentage of minority representation

One matched block group per income level was randomly selected

Prevalence of Obesity in

Block-Groups

0

5

10

15

20

25

30

35

40

45

50

Ag

e-a

dju

sted

Ob

esit

y P

rev

ale

nce

(

)

High-Income Low-Income

Age-standardized to the 1990 US Census

Density of Environmental Factors in the

Community Contributes to a ldquoToxicrdquo

Obesity Environment

0

2

4

6

8

10

12

14

16

18

Fast-food Convenience Store Bars

Den

sity

10

00

perso

ns

High-Income Low-Income

COMMUNITYrsquoS PERCEPTION OF SAFETY

0

5

10

15

20

25

30

35

40

Daytime Nighttime

Perc

en

t (

) F

eeli

ng

So

mew

hat

Safe

or

Un

safe

Low-Income High-Income

Percent Substandard (or worse) Housing

or Ground Conditions

of Residential Properties

0

10

20

30

Structural Grounds

Perc

en

t (

)

Low-Income High-Income

CONCLUSIONS

These data suggest that the higher

frequency of outlets providing

calorically-dense foods and alcohol may

contribute to greater obesity prevalence

in residents of low-income communities

More research is needed to thoroughly

document environmental determinants

of health and obesity

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

From 1994-1998 HUD randomly assigned

4498 women with children living in public

housing in high-poverty urban census

tracts to one of three groups (1) housing

vouchers redeemable only if they moved

to a low-poverty census tract (2)

unrestricted vouchers or (3) control group

(no vouchers)

Ludwig et al NEJM 201136516

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

10-12 year follow-up showed modest but

potentially important reductions in the

prevalence of extreme obesity amp diabetes in the

group moving from a neighborhood with high

poverty on one of low poverty compared to the

control group

No differences between the group receiving

traditional vouchers amp the control group

ldquoNeighborhoods matterrdquo

Ludwig et al NEJM 201136516

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance traffic safety in areas where

persons are or could be physically active

--Community-scale urban design amp land use policies to

promote physical activity including design components

to improve street lighting infrastructure projects to

increase safety of pedestrian street crossing and use of

traffic calming approaches such as speed humps amp

traffic circles are effective in increasing physical activity

--Both community-scale amp street-scale policies amp practices

are effective in increasing physical activity

Recommended Community Strategies Encourage Communities to Organize for Change

Participate in community coalitions or

partnerships to address obesity

--Little evidence is available to determine the

impact of community coalitions on obesity

prevention

--The presence of anti-smoking community

coalitions has been associated with lower rates

of tobacco consumption

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

$103 million awarded to 61 states and

communities including state amp local government

agencies tribes amp territories amp state amp local non-

profit organizations

To build capacity to implement changes for

community prevention efforts to ensure long-

term success

To implement evidence-based and practice-

based programs to improve health amp wellness

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Priority areas are

Tobacco-free living

Active living and healthy eating

Evidence-based quality clinical and other

preventive health services for prevention

and control of high blood pressure and

high cholesterol

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Applicants proposed specific activities in

line with their chosen priority areas in their

applications

Grantee activities will not be finalized until

plans are negotiated with CDC by early

2012

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Capacity-Building Award

The Confederated Tribes of The Chehalis

Reservation is receiving a $498663 planning

award to build capacity to support healthy

lifestyles among their tribal population of 1500

in Washington State

Work will target tobacco-free living active living

and healthy eating and quality clinical and other

healthy serviceswwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Implementation Award

Austin TX Dept of Health and Human Services

is receiving $1026158 to serve Travis County

(Austin) to expand efforts in tobacco-free living

active living and healthy eating quality clinical

and other preventive services social and

emotional wellness and healthy and safe

physical environmentswwwcdcgov1052011

Building sustainable healthy

communities Bottom line

Obesity is an environmental problem

Despite progress in genetic research public health advances only will occur when we take the environment seriously

Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment

Until we do this we will not make substantial progress in addressing the epidemic of obesity

Poston amp Foreyt Atherosclerosis 1999

Whatrsquos the best approach

Integrate all sectors of society into community

change interventions

Incorporate

Science amp Technology

Education

FamilyCommunity

Healthcare

Arts amp Entertainment

Law amp Politics

Commerce amp Trade

Sectors of Society

Arts amp Entertainm

ent

Commerce amp Trade

Education

FamilyCommunity

Healthcare

Law amp Politics

Science amp Technology

Project FIT rationale design and baseline characteristics of a school- and community-

based intervention to address physical activity and healthy eating among low-income

elementary school children

Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D

Oh HJ Orth J Randall S Mayfield K Holmes D

Source

Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu

Abstract

BACKGROUND

This paper describes Project FIT a collaboration between the public school system local

health systems physicians neighborhood associations businesses faith-based leaders

community agencies and university researchers to develop a multi-faceted approach to

promote physical activity and healthy eating toward the general goal of preventing and

reducing childhood obesity among children in Grand Rapids MI USA

METHODSDESIGN

There are four overall components to Project FIT school community social marketing and

school staff wellness - all that focus on 1) increasing access to safe and affordable physical

activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)

improving the affordability and availability of nutritious food in the neighborhoods surrounding

the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding

nutrition and physical activity among school staff parents and students 4) impacting the

culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging

dialogue among all community partners to leverage existing programs and introduce new

ones

Look AHEAD

Lifestyle Intervention

bull Diet

ndash ADA NCEP (lt 30 fat lt 10 sat fat

gt15 protein)

ndash 1200-1500 (if weight lt250lbs)

ndash 1500-1800 (if weight gt250lbs)

ndash During first 4 weeks to 4 months portion

control (liquid meal replacements or

structured meal plan)

Look AHEAD

Lifestyle Intervention

bull Physical Activity

ndash unsupervised

ndash 175 minutes moderate intensityweek

ndash 5 daysweek

ndash walking

Weight Loss at 1-Year

-9

ILI 0

-1

-2

-3

-4

-5

-6

-7

-8

DSE

p lt 00001

W

eig

ht

Chan

ge

86

07

The Look AHEAD Research Group Diabetes Care 2007

Reduction in Initial Weight by Gender

N=872

N=1229N=1197

N=830

-12

-10

-8

-6

-4

-2

0

0 2 4 6 8 10 12

Months

R

ed

uctio

n in

In

itia

l W

eig

ht

Men

Women

Plt0001

The Look AHEAD Research Group Diabetes Care 2007

Fitness Change () at 1-Year

0

5

10

15

20

25

Mean

Fitness C

hange

Unadjusted

Plt0001Adjusted for 1 Year

Weight Change Plt0001

58

209

108

159

DSE ILI ILIDSE

The Look AHEAD Research Group Diabetes Care 2007

1-Year Changes in Markers of

Diabetes Control

Markers of Diabetes

Control ILI DSE P-value

Hemoglobin A1c () BL

Hemoglobin A1c () Y1

Y1 ndash Baseline

725

661

-064

729

715

-014

026

lt0001

lt0001

Fasting glucose (mgdl) BL

Fasting glucose (mgdl) Y1

Y1 ndash Baseline

1519

1304

-215

1536

1464

-72

021

lt0001

lt0001

Diabetes medications BL

Diabetes medications Y1

Y1 ndash Baseline

865

786

-78

865

887

22

093

lt0001

lt0001

1-Year Changes in Markers of

Blood Pressure ControlMarkers of Blood Pressure

Control ILI DSE P-value

Systolic BP (mmHg) BL

Systolic BP (mmHg) Y1

Y1 ndash Baseline

1282

1214

-68

1294

1266

-28

026

lt0001

lt0001

Diastolic BP (mmHg) BL

Diastolic BP (mmHg) Y1

Y1 ndash Baseline

699

670

-30

704

686

-18

011

lt0001

lt0001

Antihypertensive medications BL

Antihypertensive medications Y1

Y1 ndash Baseline

753

752

-01

737

759

22

023

054

002

1-Year Changes in Markers of Lipid

Control

Markers of Lipid Control ILI DSE P-value

LDL-cholesterol (mgdl) BL

LDL-cholesterol (mgdl) Y1

Y1 ndash Baseline

1122

1070

-52

1124

1067

-57

078

074

049

HDL-cholesterol (mgdl) BL

HDL-cholesterol (mgdl) Y1

Y1 ndash Baseline

435

469

34

436

449

14

080

lt0001

lt0001

Triglycerides (mgdl) BL

Triglycerides (mgdl) Y1

Y1 ndash Baseline

1828

1525

-303

1800

1654

-146

038

lt0001

lt0001

Lipid lowering medications BL

Lipid lowering medications Y1

Y1 ndash Baseline

494

530

37

484

578

94

052

lt0001

lt0001

1-Year Changes in Percent of Participants

Meeting ADA Goals

ADA Goal ILI DSE P-value

Hemoglobin A1c lt 7 BL

Hemoglobin A1c lt 7 Y1

Y1 ndash Baseline

463

727

264

454

508

54

050

lt0001

lt0001

Blood pressure lt 13080 mmHg BL

Blood pressure lt 13080 mmHg Y1

Y1 ndash Baseline

535

686

151

499

570

70

001

lt0001

lt0001

LDL-cholesterol lt 100 mgdl BL

LDL-cholesterol lt 100 mgdl Y1

Y1 ndash Baseline

371

438

67

369

449

80

087

045

034

All three goals BL

All three goals Y1

Y1 ndash Baseline

108

236

128

95

160

65

013

lt0001

lt0001

Mean Changes in Weight Fitness amp BP

Averaged Over Four Years

DSE

Mean

ILI

Mean

P-value

Weight Loss

( initial wt)

-088 -615 lt 00001

Fitness

( METS)

196 1274 lt00001

HbA1c -009 -036 lt 00001

SBP (mm Hg) -297 -533 lt 00001

DBP (mm Hg) -248 -292 0012

Look AHEAD Research Group Arch Int Med 2010

Mean Changes in Lipid Profile

Averaged Over Four Years

DSE

Mean

ILI

Mean

P-value

HDL (mgdl) 197 367 lt00001

TG (mgdl) -1975 -2556 00006

LDL (mgdl) -1284 -1127 0009

LDL (mgdl)

(Adjusting for

medication use)

-922 -875 042

Look AHEAD Research Group Arch Int Med 2010

Percent () Completing Outcome

Measures at Years 1-4

Intervention Group

(ILI)

Year 1 971

Year 2 949

Year 3 940

Year 4 941

Comparison Group

(DSE)

Year 1 957

Year 2 935

Year 3 938

Year 4 931

Look AHEAD Summary

ILI had significantly greater improvements than DSE in all CVD risk factors averaged across 4 years (except LDL-C)

There may be long-term beneficial effects from this 4-year period in which ILI subjects have been exposed to lower CVD risk factors

Longer follow-ups will determine whether these lowered CVD risk factors can be maintained amp whether lifestyle intervention has positive effects on CVD morbidity amp mortality

Mary J

Female

White

56 years old at start of Look AHEAD

study

Past Medical History Type 2 diabetes

overweight diverticulosis arthritis

sleep apnea back pain

Mary J

bullLong term strugglesbull Helping youngest daughter with

personal issues and children

bull Rotator cuff problems

bull Degenerative disks in back

bull Rheumatoid arthritis

bull Diabetes

bull Physically demanding job

bull Financial struggles

Pounds

Years

82007 grandkids enter pre-school

Catherine L

Female

White

47 years old at start of Look AHEAD

study

Past Medical History Type 2 diabetes

overweight high blood pressure

hypothyroidism back pain

Catherine L

Long term struggles

bull Motherrsquos declining health and death

bull Multiple serious injuries

bull Sudden death of sister

bull Death of step-father

bull Declining economy

bull Children living at home

Pounds

Years

Realistic Management Goals

5-10 weight loss

Health energy and fitness

Well-being and self-esteem

Mood and appearance

Functional and recreational

activity

Key Elements

Focus on health and energy

Food and physical activity diaries

Gradual increase in physical activity

Gradual reduction in dietary fat

No feelings of food deprivation

Social support groups

Recommended Strategies for Building

Sustainable Healthy Communities

Overview from USA

Promote the availability of affordable healthy

food and beverages

Support healthy food and beverage choices

Encourage breastfeeding

Encourage physical activity or limit sedentary

activity among children amp youth

Create safe communities that support physical

activity

Encourage communities to organize for change

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Increase the availability of healthier food and

beverage choices in public service venues (eg

schools city amp county buildings etc)

--Insufficient evidence in school-based programs

--Associations suggest availability amp increased

consumption

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve availability of affordable healthier

food amp beverage choices in public service

venues

--Reducing the cost of healthier foods

increases their purchase

--Providing coupons redeemable for

healthier foods increases their purchase

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve geographic availability of

supermarkets in underserved areas

-- Greater access to nearby supermarkets is

associated with healthier eating behaviors

-- Increasing the number of supermarkets in

underserved neighborhoods increased

real estate values increased economic

activity amp employment amp resulted in lower

food prices

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Provide incentives to food retailers to locate in

andor offer healthier food choices in

underserved areas

-- Presence of retail venues that provide healthier

foods is associated with better nutrition

-- Greater availability of supermarkets was

associated with lower adolescent BMI scores

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Improve availability of mechanisms for

purchasing foods from farms

--Evidence supporting a direct link between

purchasing food from farms amp improved diet is

limited

--Two studies of initiatives to encourage

participation in farmersrsquo market showed

increased intention to eat more fruits amp

vegetables but no direct evidence

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Provide incentives for the production

distribution and procurement of foods from local

farms

--No evidence has been published to link local

food production amp health outcomes

--There is a current study exploring the potential

nutritional amp health benefits of eating locally

grown foods

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Restrict availability of less healthy foods amp

beverages in public service venues

--No peer-reviewed studies examined the impact

designed to restrict availability of less healthy

foods in public service venues

--21 states have policies that restrict the sale of

competitive foods in schools beyond USDA

regulations however no studies have evaluated

the impact of the policies

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Institute smaller portion size options in public

service venues

--Evidence is lacking to demonstrate effectiveness

of population-based interventions aimed at

reducing portion sizes in public service venues

--Evidence from clinical studies in laboratories

demonstrates decreasing portion sizes

decreases energy intake

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Limit advertisements of less healthy foods amp

beverages

--Little evidence is available regarding the impact

of restricting advertising on purchasing amp

consumption of less healthy foods

--Cross-sectional time-series studies of tobacco-

control efforts suggest an association between

advertising bans amp decreased tobacco

consumption

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Discourage consumption of sugar-sweetened

beverages

--One longitudinal study of a school-based

intervention among Native-American high school

students showed a substantial reduction in

sugar-sweetened beverages over a 3-year

period

--A RCT of a home-based intervention that

eliminated sugar-sweetened beverages showed

reduction in BMI scores

Recommended Community Strategies Strategies to encourage breastfeeding

Increase support for breastfeeding

--Evidence directly linking environmental

interventions that support breastfeeding with

obesity-related outcomes is lacking

--Epidemiologic studies indicate that breastfeeding

helps prevent pediatric obesity

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Require physical education in schools

--14 studies have demonstrated that school-based

PE was effective in increasing levels of physical

activity and improving physical fitness

--Minimum of 150 minwk in elementary schools

225 minwk in middle schools and high schools

throughout the school year as recommended by

NASPE

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Increase opportunities for extracurricular

physical activity

--Participation in after-school programs increased

studentsrsquo level of physical activity amp improved

obesity-related outcomes (improved CV fitness

reduced body fat)

--2 pilot studies providing extracurricular physical

activity showed increased levels of PA amp

decreased sedentary behavior

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Reduce screen time in public service venues

--A school-based RCT indicated that children who

reduced their television videotape amp video

game use had significant decrease in BMI tricep

skin fold thickness amp waist circumference

compared to controls

--Spending less time watching television is

associated with increased physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Improve access to outdoor recreational

facilities

--Review of 108 studies indicated that access to facilities

and programs for recreation near their homes amp time

spent outdoors correlated positively with increased

physical activity among childrenamp adults

--Perceptions that footpaths are safe for walking was

significantly associated with adults being classified as

physically active at a level sufficient for health benefits

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting

bicycling

--Longitudinal intervention studies have

demonstrated that improving bicycling

infrastructure is associated with increased

frequency of bicycling

--Cross-sectional studies indicated a significant

association between bicycling infrastructure amp

frequency of biking

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting walking

--Reviews of cross-sectional studies of

environmental correlates of physical activity amp

walking generally find a positive association

between infrastructure supportive of walking amp

physical activity

--Identifying amp creating safe routes to school

together with educational components

increased the number of students walking to

school

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Locating schools within easy walking

distance of residential areas

--Community-scale urban design amp land use policies amp

practices including locating schools stores workplaces

amp recreation areas close to residential areas are

effective in facilitating an increase in levels of physical

activity

--Majority of efforts to encourage walking to school involve

improving the routes rather than improving the location

of schools

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Improve access to public transportation

--Insufficient evidence exists to determine

effectiveness of transportation policies in

increasing the level of physical activity or

improving fitness

--1 study indicated that 29 of individuals who

walk to and from public transit achieve at least

30 minutes of daily physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Zone for mixed-use development

--Allows residential commercial institutional amp

other public land uses to be located in close

proximity to one another

--Studies using correlation analyses amp regression

models indicated that mixed land use was

associated with increased walking amp cycling

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance personal safety in areas where

persons are or could be physically active

--Cross-sectional studies have demonstrated a

negative relationship between crime rates andor

perceived safety amp physical activity in

neighborhoods

--Few intervention studies have evaluated the

impact of policies amp practices to improve

personal safety on physical activity

Geospatial Mapping Linking Urban

Environments to Health Risk

Measure association between environmental variables amp health risk factors

Assess relationships between variables at different levels of analysis

Used in conjunction with linear analyses

Our Community Environmental Model

of Obesity

Community Factors

Poverty

Crime

Grocery Quality

Restaurants

Parks

Sidewalks

Fast Food Outlets

Recreational

Facilities

Individual Factors

Dietary Intake

Physical Activity

Genetics

Family History

StressCoping

Eating Disorders

Psychological

Problems

Weight

Status

Chosen Neighborhoods

Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped

We then matched census-block groups within the income groups by population density and percentage of minority representation

One matched block group per income level was randomly selected

Prevalence of Obesity in

Block-Groups

0

5

10

15

20

25

30

35

40

45

50

Ag

e-a

dju

sted

Ob

esit

y P

rev

ale

nce

(

)

High-Income Low-Income

Age-standardized to the 1990 US Census

Density of Environmental Factors in the

Community Contributes to a ldquoToxicrdquo

Obesity Environment

0

2

4

6

8

10

12

14

16

18

Fast-food Convenience Store Bars

Den

sity

10

00

perso

ns

High-Income Low-Income

COMMUNITYrsquoS PERCEPTION OF SAFETY

0

5

10

15

20

25

30

35

40

Daytime Nighttime

Perc

en

t (

) F

eeli

ng

So

mew

hat

Safe

or

Un

safe

Low-Income High-Income

Percent Substandard (or worse) Housing

or Ground Conditions

of Residential Properties

0

10

20

30

Structural Grounds

Perc

en

t (

)

Low-Income High-Income

CONCLUSIONS

These data suggest that the higher

frequency of outlets providing

calorically-dense foods and alcohol may

contribute to greater obesity prevalence

in residents of low-income communities

More research is needed to thoroughly

document environmental determinants

of health and obesity

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

From 1994-1998 HUD randomly assigned

4498 women with children living in public

housing in high-poverty urban census

tracts to one of three groups (1) housing

vouchers redeemable only if they moved

to a low-poverty census tract (2)

unrestricted vouchers or (3) control group

(no vouchers)

Ludwig et al NEJM 201136516

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

10-12 year follow-up showed modest but

potentially important reductions in the

prevalence of extreme obesity amp diabetes in the

group moving from a neighborhood with high

poverty on one of low poverty compared to the

control group

No differences between the group receiving

traditional vouchers amp the control group

ldquoNeighborhoods matterrdquo

Ludwig et al NEJM 201136516

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance traffic safety in areas where

persons are or could be physically active

--Community-scale urban design amp land use policies to

promote physical activity including design components

to improve street lighting infrastructure projects to

increase safety of pedestrian street crossing and use of

traffic calming approaches such as speed humps amp

traffic circles are effective in increasing physical activity

--Both community-scale amp street-scale policies amp practices

are effective in increasing physical activity

Recommended Community Strategies Encourage Communities to Organize for Change

Participate in community coalitions or

partnerships to address obesity

--Little evidence is available to determine the

impact of community coalitions on obesity

prevention

--The presence of anti-smoking community

coalitions has been associated with lower rates

of tobacco consumption

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

$103 million awarded to 61 states and

communities including state amp local government

agencies tribes amp territories amp state amp local non-

profit organizations

To build capacity to implement changes for

community prevention efforts to ensure long-

term success

To implement evidence-based and practice-

based programs to improve health amp wellness

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Priority areas are

Tobacco-free living

Active living and healthy eating

Evidence-based quality clinical and other

preventive health services for prevention

and control of high blood pressure and

high cholesterol

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Applicants proposed specific activities in

line with their chosen priority areas in their

applications

Grantee activities will not be finalized until

plans are negotiated with CDC by early

2012

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Capacity-Building Award

The Confederated Tribes of The Chehalis

Reservation is receiving a $498663 planning

award to build capacity to support healthy

lifestyles among their tribal population of 1500

in Washington State

Work will target tobacco-free living active living

and healthy eating and quality clinical and other

healthy serviceswwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Implementation Award

Austin TX Dept of Health and Human Services

is receiving $1026158 to serve Travis County

(Austin) to expand efforts in tobacco-free living

active living and healthy eating quality clinical

and other preventive services social and

emotional wellness and healthy and safe

physical environmentswwwcdcgov1052011

Building sustainable healthy

communities Bottom line

Obesity is an environmental problem

Despite progress in genetic research public health advances only will occur when we take the environment seriously

Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment

Until we do this we will not make substantial progress in addressing the epidemic of obesity

Poston amp Foreyt Atherosclerosis 1999

Whatrsquos the best approach

Integrate all sectors of society into community

change interventions

Incorporate

Science amp Technology

Education

FamilyCommunity

Healthcare

Arts amp Entertainment

Law amp Politics

Commerce amp Trade

Sectors of Society

Arts amp Entertainm

ent

Commerce amp Trade

Education

FamilyCommunity

Healthcare

Law amp Politics

Science amp Technology

Project FIT rationale design and baseline characteristics of a school- and community-

based intervention to address physical activity and healthy eating among low-income

elementary school children

Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D

Oh HJ Orth J Randall S Mayfield K Holmes D

Source

Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu

Abstract

BACKGROUND

This paper describes Project FIT a collaboration between the public school system local

health systems physicians neighborhood associations businesses faith-based leaders

community agencies and university researchers to develop a multi-faceted approach to

promote physical activity and healthy eating toward the general goal of preventing and

reducing childhood obesity among children in Grand Rapids MI USA

METHODSDESIGN

There are four overall components to Project FIT school community social marketing and

school staff wellness - all that focus on 1) increasing access to safe and affordable physical

activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)

improving the affordability and availability of nutritious food in the neighborhoods surrounding

the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding

nutrition and physical activity among school staff parents and students 4) impacting the

culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging

dialogue among all community partners to leverage existing programs and introduce new

ones

Look AHEAD

Lifestyle Intervention

bull Physical Activity

ndash unsupervised

ndash 175 minutes moderate intensityweek

ndash 5 daysweek

ndash walking

Weight Loss at 1-Year

-9

ILI 0

-1

-2

-3

-4

-5

-6

-7

-8

DSE

p lt 00001

W

eig

ht

Chan

ge

86

07

The Look AHEAD Research Group Diabetes Care 2007

Reduction in Initial Weight by Gender

N=872

N=1229N=1197

N=830

-12

-10

-8

-6

-4

-2

0

0 2 4 6 8 10 12

Months

R

ed

uctio

n in

In

itia

l W

eig

ht

Men

Women

Plt0001

The Look AHEAD Research Group Diabetes Care 2007

Fitness Change () at 1-Year

0

5

10

15

20

25

Mean

Fitness C

hange

Unadjusted

Plt0001Adjusted for 1 Year

Weight Change Plt0001

58

209

108

159

DSE ILI ILIDSE

The Look AHEAD Research Group Diabetes Care 2007

1-Year Changes in Markers of

Diabetes Control

Markers of Diabetes

Control ILI DSE P-value

Hemoglobin A1c () BL

Hemoglobin A1c () Y1

Y1 ndash Baseline

725

661

-064

729

715

-014

026

lt0001

lt0001

Fasting glucose (mgdl) BL

Fasting glucose (mgdl) Y1

Y1 ndash Baseline

1519

1304

-215

1536

1464

-72

021

lt0001

lt0001

Diabetes medications BL

Diabetes medications Y1

Y1 ndash Baseline

865

786

-78

865

887

22

093

lt0001

lt0001

1-Year Changes in Markers of

Blood Pressure ControlMarkers of Blood Pressure

Control ILI DSE P-value

Systolic BP (mmHg) BL

Systolic BP (mmHg) Y1

Y1 ndash Baseline

1282

1214

-68

1294

1266

-28

026

lt0001

lt0001

Diastolic BP (mmHg) BL

Diastolic BP (mmHg) Y1

Y1 ndash Baseline

699

670

-30

704

686

-18

011

lt0001

lt0001

Antihypertensive medications BL

Antihypertensive medications Y1

Y1 ndash Baseline

753

752

-01

737

759

22

023

054

002

1-Year Changes in Markers of Lipid

Control

Markers of Lipid Control ILI DSE P-value

LDL-cholesterol (mgdl) BL

LDL-cholesterol (mgdl) Y1

Y1 ndash Baseline

1122

1070

-52

1124

1067

-57

078

074

049

HDL-cholesterol (mgdl) BL

HDL-cholesterol (mgdl) Y1

Y1 ndash Baseline

435

469

34

436

449

14

080

lt0001

lt0001

Triglycerides (mgdl) BL

Triglycerides (mgdl) Y1

Y1 ndash Baseline

1828

1525

-303

1800

1654

-146

038

lt0001

lt0001

Lipid lowering medications BL

Lipid lowering medications Y1

Y1 ndash Baseline

494

530

37

484

578

94

052

lt0001

lt0001

1-Year Changes in Percent of Participants

Meeting ADA Goals

ADA Goal ILI DSE P-value

Hemoglobin A1c lt 7 BL

Hemoglobin A1c lt 7 Y1

Y1 ndash Baseline

463

727

264

454

508

54

050

lt0001

lt0001

Blood pressure lt 13080 mmHg BL

Blood pressure lt 13080 mmHg Y1

Y1 ndash Baseline

535

686

151

499

570

70

001

lt0001

lt0001

LDL-cholesterol lt 100 mgdl BL

LDL-cholesterol lt 100 mgdl Y1

Y1 ndash Baseline

371

438

67

369

449

80

087

045

034

All three goals BL

All three goals Y1

Y1 ndash Baseline

108

236

128

95

160

65

013

lt0001

lt0001

Mean Changes in Weight Fitness amp BP

Averaged Over Four Years

DSE

Mean

ILI

Mean

P-value

Weight Loss

( initial wt)

-088 -615 lt 00001

Fitness

( METS)

196 1274 lt00001

HbA1c -009 -036 lt 00001

SBP (mm Hg) -297 -533 lt 00001

DBP (mm Hg) -248 -292 0012

Look AHEAD Research Group Arch Int Med 2010

Mean Changes in Lipid Profile

Averaged Over Four Years

DSE

Mean

ILI

Mean

P-value

HDL (mgdl) 197 367 lt00001

TG (mgdl) -1975 -2556 00006

LDL (mgdl) -1284 -1127 0009

LDL (mgdl)

(Adjusting for

medication use)

-922 -875 042

Look AHEAD Research Group Arch Int Med 2010

Percent () Completing Outcome

Measures at Years 1-4

Intervention Group

(ILI)

Year 1 971

Year 2 949

Year 3 940

Year 4 941

Comparison Group

(DSE)

Year 1 957

Year 2 935

Year 3 938

Year 4 931

Look AHEAD Summary

ILI had significantly greater improvements than DSE in all CVD risk factors averaged across 4 years (except LDL-C)

There may be long-term beneficial effects from this 4-year period in which ILI subjects have been exposed to lower CVD risk factors

Longer follow-ups will determine whether these lowered CVD risk factors can be maintained amp whether lifestyle intervention has positive effects on CVD morbidity amp mortality

Mary J

Female

White

56 years old at start of Look AHEAD

study

Past Medical History Type 2 diabetes

overweight diverticulosis arthritis

sleep apnea back pain

Mary J

bullLong term strugglesbull Helping youngest daughter with

personal issues and children

bull Rotator cuff problems

bull Degenerative disks in back

bull Rheumatoid arthritis

bull Diabetes

bull Physically demanding job

bull Financial struggles

Pounds

Years

82007 grandkids enter pre-school

Catherine L

Female

White

47 years old at start of Look AHEAD

study

Past Medical History Type 2 diabetes

overweight high blood pressure

hypothyroidism back pain

Catherine L

Long term struggles

bull Motherrsquos declining health and death

bull Multiple serious injuries

bull Sudden death of sister

bull Death of step-father

bull Declining economy

bull Children living at home

Pounds

Years

Realistic Management Goals

5-10 weight loss

Health energy and fitness

Well-being and self-esteem

Mood and appearance

Functional and recreational

activity

Key Elements

Focus on health and energy

Food and physical activity diaries

Gradual increase in physical activity

Gradual reduction in dietary fat

No feelings of food deprivation

Social support groups

Recommended Strategies for Building

Sustainable Healthy Communities

Overview from USA

Promote the availability of affordable healthy

food and beverages

Support healthy food and beverage choices

Encourage breastfeeding

Encourage physical activity or limit sedentary

activity among children amp youth

Create safe communities that support physical

activity

Encourage communities to organize for change

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Increase the availability of healthier food and

beverage choices in public service venues (eg

schools city amp county buildings etc)

--Insufficient evidence in school-based programs

--Associations suggest availability amp increased

consumption

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve availability of affordable healthier

food amp beverage choices in public service

venues

--Reducing the cost of healthier foods

increases their purchase

--Providing coupons redeemable for

healthier foods increases their purchase

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve geographic availability of

supermarkets in underserved areas

-- Greater access to nearby supermarkets is

associated with healthier eating behaviors

-- Increasing the number of supermarkets in

underserved neighborhoods increased

real estate values increased economic

activity amp employment amp resulted in lower

food prices

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Provide incentives to food retailers to locate in

andor offer healthier food choices in

underserved areas

-- Presence of retail venues that provide healthier

foods is associated with better nutrition

-- Greater availability of supermarkets was

associated with lower adolescent BMI scores

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Improve availability of mechanisms for

purchasing foods from farms

--Evidence supporting a direct link between

purchasing food from farms amp improved diet is

limited

--Two studies of initiatives to encourage

participation in farmersrsquo market showed

increased intention to eat more fruits amp

vegetables but no direct evidence

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Provide incentives for the production

distribution and procurement of foods from local

farms

--No evidence has been published to link local

food production amp health outcomes

--There is a current study exploring the potential

nutritional amp health benefits of eating locally

grown foods

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Restrict availability of less healthy foods amp

beverages in public service venues

--No peer-reviewed studies examined the impact

designed to restrict availability of less healthy

foods in public service venues

--21 states have policies that restrict the sale of

competitive foods in schools beyond USDA

regulations however no studies have evaluated

the impact of the policies

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Institute smaller portion size options in public

service venues

--Evidence is lacking to demonstrate effectiveness

of population-based interventions aimed at

reducing portion sizes in public service venues

--Evidence from clinical studies in laboratories

demonstrates decreasing portion sizes

decreases energy intake

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Limit advertisements of less healthy foods amp

beverages

--Little evidence is available regarding the impact

of restricting advertising on purchasing amp

consumption of less healthy foods

--Cross-sectional time-series studies of tobacco-

control efforts suggest an association between

advertising bans amp decreased tobacco

consumption

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Discourage consumption of sugar-sweetened

beverages

--One longitudinal study of a school-based

intervention among Native-American high school

students showed a substantial reduction in

sugar-sweetened beverages over a 3-year

period

--A RCT of a home-based intervention that

eliminated sugar-sweetened beverages showed

reduction in BMI scores

Recommended Community Strategies Strategies to encourage breastfeeding

Increase support for breastfeeding

--Evidence directly linking environmental

interventions that support breastfeeding with

obesity-related outcomes is lacking

--Epidemiologic studies indicate that breastfeeding

helps prevent pediatric obesity

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Require physical education in schools

--14 studies have demonstrated that school-based

PE was effective in increasing levels of physical

activity and improving physical fitness

--Minimum of 150 minwk in elementary schools

225 minwk in middle schools and high schools

throughout the school year as recommended by

NASPE

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Increase opportunities for extracurricular

physical activity

--Participation in after-school programs increased

studentsrsquo level of physical activity amp improved

obesity-related outcomes (improved CV fitness

reduced body fat)

--2 pilot studies providing extracurricular physical

activity showed increased levels of PA amp

decreased sedentary behavior

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Reduce screen time in public service venues

--A school-based RCT indicated that children who

reduced their television videotape amp video

game use had significant decrease in BMI tricep

skin fold thickness amp waist circumference

compared to controls

--Spending less time watching television is

associated with increased physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Improve access to outdoor recreational

facilities

--Review of 108 studies indicated that access to facilities

and programs for recreation near their homes amp time

spent outdoors correlated positively with increased

physical activity among childrenamp adults

--Perceptions that footpaths are safe for walking was

significantly associated with adults being classified as

physically active at a level sufficient for health benefits

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting

bicycling

--Longitudinal intervention studies have

demonstrated that improving bicycling

infrastructure is associated with increased

frequency of bicycling

--Cross-sectional studies indicated a significant

association between bicycling infrastructure amp

frequency of biking

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting walking

--Reviews of cross-sectional studies of

environmental correlates of physical activity amp

walking generally find a positive association

between infrastructure supportive of walking amp

physical activity

--Identifying amp creating safe routes to school

together with educational components

increased the number of students walking to

school

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Locating schools within easy walking

distance of residential areas

--Community-scale urban design amp land use policies amp

practices including locating schools stores workplaces

amp recreation areas close to residential areas are

effective in facilitating an increase in levels of physical

activity

--Majority of efforts to encourage walking to school involve

improving the routes rather than improving the location

of schools

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Improve access to public transportation

--Insufficient evidence exists to determine

effectiveness of transportation policies in

increasing the level of physical activity or

improving fitness

--1 study indicated that 29 of individuals who

walk to and from public transit achieve at least

30 minutes of daily physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Zone for mixed-use development

--Allows residential commercial institutional amp

other public land uses to be located in close

proximity to one another

--Studies using correlation analyses amp regression

models indicated that mixed land use was

associated with increased walking amp cycling

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance personal safety in areas where

persons are or could be physically active

--Cross-sectional studies have demonstrated a

negative relationship between crime rates andor

perceived safety amp physical activity in

neighborhoods

--Few intervention studies have evaluated the

impact of policies amp practices to improve

personal safety on physical activity

Geospatial Mapping Linking Urban

Environments to Health Risk

Measure association between environmental variables amp health risk factors

Assess relationships between variables at different levels of analysis

Used in conjunction with linear analyses

Our Community Environmental Model

of Obesity

Community Factors

Poverty

Crime

Grocery Quality

Restaurants

Parks

Sidewalks

Fast Food Outlets

Recreational

Facilities

Individual Factors

Dietary Intake

Physical Activity

Genetics

Family History

StressCoping

Eating Disorders

Psychological

Problems

Weight

Status

Chosen Neighborhoods

Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped

We then matched census-block groups within the income groups by population density and percentage of minority representation

One matched block group per income level was randomly selected

Prevalence of Obesity in

Block-Groups

0

5

10

15

20

25

30

35

40

45

50

Ag

e-a

dju

sted

Ob

esit

y P

rev

ale

nce

(

)

High-Income Low-Income

Age-standardized to the 1990 US Census

Density of Environmental Factors in the

Community Contributes to a ldquoToxicrdquo

Obesity Environment

0

2

4

6

8

10

12

14

16

18

Fast-food Convenience Store Bars

Den

sity

10

00

perso

ns

High-Income Low-Income

COMMUNITYrsquoS PERCEPTION OF SAFETY

0

5

10

15

20

25

30

35

40

Daytime Nighttime

Perc

en

t (

) F

eeli

ng

So

mew

hat

Safe

or

Un

safe

Low-Income High-Income

Percent Substandard (or worse) Housing

or Ground Conditions

of Residential Properties

0

10

20

30

Structural Grounds

Perc

en

t (

)

Low-Income High-Income

CONCLUSIONS

These data suggest that the higher

frequency of outlets providing

calorically-dense foods and alcohol may

contribute to greater obesity prevalence

in residents of low-income communities

More research is needed to thoroughly

document environmental determinants

of health and obesity

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

From 1994-1998 HUD randomly assigned

4498 women with children living in public

housing in high-poverty urban census

tracts to one of three groups (1) housing

vouchers redeemable only if they moved

to a low-poverty census tract (2)

unrestricted vouchers or (3) control group

(no vouchers)

Ludwig et al NEJM 201136516

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

10-12 year follow-up showed modest but

potentially important reductions in the

prevalence of extreme obesity amp diabetes in the

group moving from a neighborhood with high

poverty on one of low poverty compared to the

control group

No differences between the group receiving

traditional vouchers amp the control group

ldquoNeighborhoods matterrdquo

Ludwig et al NEJM 201136516

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance traffic safety in areas where

persons are or could be physically active

--Community-scale urban design amp land use policies to

promote physical activity including design components

to improve street lighting infrastructure projects to

increase safety of pedestrian street crossing and use of

traffic calming approaches such as speed humps amp

traffic circles are effective in increasing physical activity

--Both community-scale amp street-scale policies amp practices

are effective in increasing physical activity

Recommended Community Strategies Encourage Communities to Organize for Change

Participate in community coalitions or

partnerships to address obesity

--Little evidence is available to determine the

impact of community coalitions on obesity

prevention

--The presence of anti-smoking community

coalitions has been associated with lower rates

of tobacco consumption

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

$103 million awarded to 61 states and

communities including state amp local government

agencies tribes amp territories amp state amp local non-

profit organizations

To build capacity to implement changes for

community prevention efforts to ensure long-

term success

To implement evidence-based and practice-

based programs to improve health amp wellness

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Priority areas are

Tobacco-free living

Active living and healthy eating

Evidence-based quality clinical and other

preventive health services for prevention

and control of high blood pressure and

high cholesterol

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Applicants proposed specific activities in

line with their chosen priority areas in their

applications

Grantee activities will not be finalized until

plans are negotiated with CDC by early

2012

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Capacity-Building Award

The Confederated Tribes of The Chehalis

Reservation is receiving a $498663 planning

award to build capacity to support healthy

lifestyles among their tribal population of 1500

in Washington State

Work will target tobacco-free living active living

and healthy eating and quality clinical and other

healthy serviceswwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Implementation Award

Austin TX Dept of Health and Human Services

is receiving $1026158 to serve Travis County

(Austin) to expand efforts in tobacco-free living

active living and healthy eating quality clinical

and other preventive services social and

emotional wellness and healthy and safe

physical environmentswwwcdcgov1052011

Building sustainable healthy

communities Bottom line

Obesity is an environmental problem

Despite progress in genetic research public health advances only will occur when we take the environment seriously

Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment

Until we do this we will not make substantial progress in addressing the epidemic of obesity

Poston amp Foreyt Atherosclerosis 1999

Whatrsquos the best approach

Integrate all sectors of society into community

change interventions

Incorporate

Science amp Technology

Education

FamilyCommunity

Healthcare

Arts amp Entertainment

Law amp Politics

Commerce amp Trade

Sectors of Society

Arts amp Entertainm

ent

Commerce amp Trade

Education

FamilyCommunity

Healthcare

Law amp Politics

Science amp Technology

Project FIT rationale design and baseline characteristics of a school- and community-

based intervention to address physical activity and healthy eating among low-income

elementary school children

Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D

Oh HJ Orth J Randall S Mayfield K Holmes D

Source

Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu

Abstract

BACKGROUND

This paper describes Project FIT a collaboration between the public school system local

health systems physicians neighborhood associations businesses faith-based leaders

community agencies and university researchers to develop a multi-faceted approach to

promote physical activity and healthy eating toward the general goal of preventing and

reducing childhood obesity among children in Grand Rapids MI USA

METHODSDESIGN

There are four overall components to Project FIT school community social marketing and

school staff wellness - all that focus on 1) increasing access to safe and affordable physical

activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)

improving the affordability and availability of nutritious food in the neighborhoods surrounding

the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding

nutrition and physical activity among school staff parents and students 4) impacting the

culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging

dialogue among all community partners to leverage existing programs and introduce new

ones

Weight Loss at 1-Year

-9

ILI 0

-1

-2

-3

-4

-5

-6

-7

-8

DSE

p lt 00001

W

eig

ht

Chan

ge

86

07

The Look AHEAD Research Group Diabetes Care 2007

Reduction in Initial Weight by Gender

N=872

N=1229N=1197

N=830

-12

-10

-8

-6

-4

-2

0

0 2 4 6 8 10 12

Months

R

ed

uctio

n in

In

itia

l W

eig

ht

Men

Women

Plt0001

The Look AHEAD Research Group Diabetes Care 2007

Fitness Change () at 1-Year

0

5

10

15

20

25

Mean

Fitness C

hange

Unadjusted

Plt0001Adjusted for 1 Year

Weight Change Plt0001

58

209

108

159

DSE ILI ILIDSE

The Look AHEAD Research Group Diabetes Care 2007

1-Year Changes in Markers of

Diabetes Control

Markers of Diabetes

Control ILI DSE P-value

Hemoglobin A1c () BL

Hemoglobin A1c () Y1

Y1 ndash Baseline

725

661

-064

729

715

-014

026

lt0001

lt0001

Fasting glucose (mgdl) BL

Fasting glucose (mgdl) Y1

Y1 ndash Baseline

1519

1304

-215

1536

1464

-72

021

lt0001

lt0001

Diabetes medications BL

Diabetes medications Y1

Y1 ndash Baseline

865

786

-78

865

887

22

093

lt0001

lt0001

1-Year Changes in Markers of

Blood Pressure ControlMarkers of Blood Pressure

Control ILI DSE P-value

Systolic BP (mmHg) BL

Systolic BP (mmHg) Y1

Y1 ndash Baseline

1282

1214

-68

1294

1266

-28

026

lt0001

lt0001

Diastolic BP (mmHg) BL

Diastolic BP (mmHg) Y1

Y1 ndash Baseline

699

670

-30

704

686

-18

011

lt0001

lt0001

Antihypertensive medications BL

Antihypertensive medications Y1

Y1 ndash Baseline

753

752

-01

737

759

22

023

054

002

1-Year Changes in Markers of Lipid

Control

Markers of Lipid Control ILI DSE P-value

LDL-cholesterol (mgdl) BL

LDL-cholesterol (mgdl) Y1

Y1 ndash Baseline

1122

1070

-52

1124

1067

-57

078

074

049

HDL-cholesterol (mgdl) BL

HDL-cholesterol (mgdl) Y1

Y1 ndash Baseline

435

469

34

436

449

14

080

lt0001

lt0001

Triglycerides (mgdl) BL

Triglycerides (mgdl) Y1

Y1 ndash Baseline

1828

1525

-303

1800

1654

-146

038

lt0001

lt0001

Lipid lowering medications BL

Lipid lowering medications Y1

Y1 ndash Baseline

494

530

37

484

578

94

052

lt0001

lt0001

1-Year Changes in Percent of Participants

Meeting ADA Goals

ADA Goal ILI DSE P-value

Hemoglobin A1c lt 7 BL

Hemoglobin A1c lt 7 Y1

Y1 ndash Baseline

463

727

264

454

508

54

050

lt0001

lt0001

Blood pressure lt 13080 mmHg BL

Blood pressure lt 13080 mmHg Y1

Y1 ndash Baseline

535

686

151

499

570

70

001

lt0001

lt0001

LDL-cholesterol lt 100 mgdl BL

LDL-cholesterol lt 100 mgdl Y1

Y1 ndash Baseline

371

438

67

369

449

80

087

045

034

All three goals BL

All three goals Y1

Y1 ndash Baseline

108

236

128

95

160

65

013

lt0001

lt0001

Mean Changes in Weight Fitness amp BP

Averaged Over Four Years

DSE

Mean

ILI

Mean

P-value

Weight Loss

( initial wt)

-088 -615 lt 00001

Fitness

( METS)

196 1274 lt00001

HbA1c -009 -036 lt 00001

SBP (mm Hg) -297 -533 lt 00001

DBP (mm Hg) -248 -292 0012

Look AHEAD Research Group Arch Int Med 2010

Mean Changes in Lipid Profile

Averaged Over Four Years

DSE

Mean

ILI

Mean

P-value

HDL (mgdl) 197 367 lt00001

TG (mgdl) -1975 -2556 00006

LDL (mgdl) -1284 -1127 0009

LDL (mgdl)

(Adjusting for

medication use)

-922 -875 042

Look AHEAD Research Group Arch Int Med 2010

Percent () Completing Outcome

Measures at Years 1-4

Intervention Group

(ILI)

Year 1 971

Year 2 949

Year 3 940

Year 4 941

Comparison Group

(DSE)

Year 1 957

Year 2 935

Year 3 938

Year 4 931

Look AHEAD Summary

ILI had significantly greater improvements than DSE in all CVD risk factors averaged across 4 years (except LDL-C)

There may be long-term beneficial effects from this 4-year period in which ILI subjects have been exposed to lower CVD risk factors

Longer follow-ups will determine whether these lowered CVD risk factors can be maintained amp whether lifestyle intervention has positive effects on CVD morbidity amp mortality

Mary J

Female

White

56 years old at start of Look AHEAD

study

Past Medical History Type 2 diabetes

overweight diverticulosis arthritis

sleep apnea back pain

Mary J

bullLong term strugglesbull Helping youngest daughter with

personal issues and children

bull Rotator cuff problems

bull Degenerative disks in back

bull Rheumatoid arthritis

bull Diabetes

bull Physically demanding job

bull Financial struggles

Pounds

Years

82007 grandkids enter pre-school

Catherine L

Female

White

47 years old at start of Look AHEAD

study

Past Medical History Type 2 diabetes

overweight high blood pressure

hypothyroidism back pain

Catherine L

Long term struggles

bull Motherrsquos declining health and death

bull Multiple serious injuries

bull Sudden death of sister

bull Death of step-father

bull Declining economy

bull Children living at home

Pounds

Years

Realistic Management Goals

5-10 weight loss

Health energy and fitness

Well-being and self-esteem

Mood and appearance

Functional and recreational

activity

Key Elements

Focus on health and energy

Food and physical activity diaries

Gradual increase in physical activity

Gradual reduction in dietary fat

No feelings of food deprivation

Social support groups

Recommended Strategies for Building

Sustainable Healthy Communities

Overview from USA

Promote the availability of affordable healthy

food and beverages

Support healthy food and beverage choices

Encourage breastfeeding

Encourage physical activity or limit sedentary

activity among children amp youth

Create safe communities that support physical

activity

Encourage communities to organize for change

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Increase the availability of healthier food and

beverage choices in public service venues (eg

schools city amp county buildings etc)

--Insufficient evidence in school-based programs

--Associations suggest availability amp increased

consumption

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve availability of affordable healthier

food amp beverage choices in public service

venues

--Reducing the cost of healthier foods

increases their purchase

--Providing coupons redeemable for

healthier foods increases their purchase

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve geographic availability of

supermarkets in underserved areas

-- Greater access to nearby supermarkets is

associated with healthier eating behaviors

-- Increasing the number of supermarkets in

underserved neighborhoods increased

real estate values increased economic

activity amp employment amp resulted in lower

food prices

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Provide incentives to food retailers to locate in

andor offer healthier food choices in

underserved areas

-- Presence of retail venues that provide healthier

foods is associated with better nutrition

-- Greater availability of supermarkets was

associated with lower adolescent BMI scores

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Improve availability of mechanisms for

purchasing foods from farms

--Evidence supporting a direct link between

purchasing food from farms amp improved diet is

limited

--Two studies of initiatives to encourage

participation in farmersrsquo market showed

increased intention to eat more fruits amp

vegetables but no direct evidence

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Provide incentives for the production

distribution and procurement of foods from local

farms

--No evidence has been published to link local

food production amp health outcomes

--There is a current study exploring the potential

nutritional amp health benefits of eating locally

grown foods

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Restrict availability of less healthy foods amp

beverages in public service venues

--No peer-reviewed studies examined the impact

designed to restrict availability of less healthy

foods in public service venues

--21 states have policies that restrict the sale of

competitive foods in schools beyond USDA

regulations however no studies have evaluated

the impact of the policies

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Institute smaller portion size options in public

service venues

--Evidence is lacking to demonstrate effectiveness

of population-based interventions aimed at

reducing portion sizes in public service venues

--Evidence from clinical studies in laboratories

demonstrates decreasing portion sizes

decreases energy intake

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Limit advertisements of less healthy foods amp

beverages

--Little evidence is available regarding the impact

of restricting advertising on purchasing amp

consumption of less healthy foods

--Cross-sectional time-series studies of tobacco-

control efforts suggest an association between

advertising bans amp decreased tobacco

consumption

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Discourage consumption of sugar-sweetened

beverages

--One longitudinal study of a school-based

intervention among Native-American high school

students showed a substantial reduction in

sugar-sweetened beverages over a 3-year

period

--A RCT of a home-based intervention that

eliminated sugar-sweetened beverages showed

reduction in BMI scores

Recommended Community Strategies Strategies to encourage breastfeeding

Increase support for breastfeeding

--Evidence directly linking environmental

interventions that support breastfeeding with

obesity-related outcomes is lacking

--Epidemiologic studies indicate that breastfeeding

helps prevent pediatric obesity

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Require physical education in schools

--14 studies have demonstrated that school-based

PE was effective in increasing levels of physical

activity and improving physical fitness

--Minimum of 150 minwk in elementary schools

225 minwk in middle schools and high schools

throughout the school year as recommended by

NASPE

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Increase opportunities for extracurricular

physical activity

--Participation in after-school programs increased

studentsrsquo level of physical activity amp improved

obesity-related outcomes (improved CV fitness

reduced body fat)

--2 pilot studies providing extracurricular physical

activity showed increased levels of PA amp

decreased sedentary behavior

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Reduce screen time in public service venues

--A school-based RCT indicated that children who

reduced their television videotape amp video

game use had significant decrease in BMI tricep

skin fold thickness amp waist circumference

compared to controls

--Spending less time watching television is

associated with increased physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Improve access to outdoor recreational

facilities

--Review of 108 studies indicated that access to facilities

and programs for recreation near their homes amp time

spent outdoors correlated positively with increased

physical activity among childrenamp adults

--Perceptions that footpaths are safe for walking was

significantly associated with adults being classified as

physically active at a level sufficient for health benefits

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting

bicycling

--Longitudinal intervention studies have

demonstrated that improving bicycling

infrastructure is associated with increased

frequency of bicycling

--Cross-sectional studies indicated a significant

association between bicycling infrastructure amp

frequency of biking

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting walking

--Reviews of cross-sectional studies of

environmental correlates of physical activity amp

walking generally find a positive association

between infrastructure supportive of walking amp

physical activity

--Identifying amp creating safe routes to school

together with educational components

increased the number of students walking to

school

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Locating schools within easy walking

distance of residential areas

--Community-scale urban design amp land use policies amp

practices including locating schools stores workplaces

amp recreation areas close to residential areas are

effective in facilitating an increase in levels of physical

activity

--Majority of efforts to encourage walking to school involve

improving the routes rather than improving the location

of schools

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Improve access to public transportation

--Insufficient evidence exists to determine

effectiveness of transportation policies in

increasing the level of physical activity or

improving fitness

--1 study indicated that 29 of individuals who

walk to and from public transit achieve at least

30 minutes of daily physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Zone for mixed-use development

--Allows residential commercial institutional amp

other public land uses to be located in close

proximity to one another

--Studies using correlation analyses amp regression

models indicated that mixed land use was

associated with increased walking amp cycling

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance personal safety in areas where

persons are or could be physically active

--Cross-sectional studies have demonstrated a

negative relationship between crime rates andor

perceived safety amp physical activity in

neighborhoods

--Few intervention studies have evaluated the

impact of policies amp practices to improve

personal safety on physical activity

Geospatial Mapping Linking Urban

Environments to Health Risk

Measure association between environmental variables amp health risk factors

Assess relationships between variables at different levels of analysis

Used in conjunction with linear analyses

Our Community Environmental Model

of Obesity

Community Factors

Poverty

Crime

Grocery Quality

Restaurants

Parks

Sidewalks

Fast Food Outlets

Recreational

Facilities

Individual Factors

Dietary Intake

Physical Activity

Genetics

Family History

StressCoping

Eating Disorders

Psychological

Problems

Weight

Status

Chosen Neighborhoods

Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped

We then matched census-block groups within the income groups by population density and percentage of minority representation

One matched block group per income level was randomly selected

Prevalence of Obesity in

Block-Groups

0

5

10

15

20

25

30

35

40

45

50

Ag

e-a

dju

sted

Ob

esit

y P

rev

ale

nce

(

)

High-Income Low-Income

Age-standardized to the 1990 US Census

Density of Environmental Factors in the

Community Contributes to a ldquoToxicrdquo

Obesity Environment

0

2

4

6

8

10

12

14

16

18

Fast-food Convenience Store Bars

Den

sity

10

00

perso

ns

High-Income Low-Income

COMMUNITYrsquoS PERCEPTION OF SAFETY

0

5

10

15

20

25

30

35

40

Daytime Nighttime

Perc

en

t (

) F

eeli

ng

So

mew

hat

Safe

or

Un

safe

Low-Income High-Income

Percent Substandard (or worse) Housing

or Ground Conditions

of Residential Properties

0

10

20

30

Structural Grounds

Perc

en

t (

)

Low-Income High-Income

CONCLUSIONS

These data suggest that the higher

frequency of outlets providing

calorically-dense foods and alcohol may

contribute to greater obesity prevalence

in residents of low-income communities

More research is needed to thoroughly

document environmental determinants

of health and obesity

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

From 1994-1998 HUD randomly assigned

4498 women with children living in public

housing in high-poverty urban census

tracts to one of three groups (1) housing

vouchers redeemable only if they moved

to a low-poverty census tract (2)

unrestricted vouchers or (3) control group

(no vouchers)

Ludwig et al NEJM 201136516

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

10-12 year follow-up showed modest but

potentially important reductions in the

prevalence of extreme obesity amp diabetes in the

group moving from a neighborhood with high

poverty on one of low poverty compared to the

control group

No differences between the group receiving

traditional vouchers amp the control group

ldquoNeighborhoods matterrdquo

Ludwig et al NEJM 201136516

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance traffic safety in areas where

persons are or could be physically active

--Community-scale urban design amp land use policies to

promote physical activity including design components

to improve street lighting infrastructure projects to

increase safety of pedestrian street crossing and use of

traffic calming approaches such as speed humps amp

traffic circles are effective in increasing physical activity

--Both community-scale amp street-scale policies amp practices

are effective in increasing physical activity

Recommended Community Strategies Encourage Communities to Organize for Change

Participate in community coalitions or

partnerships to address obesity

--Little evidence is available to determine the

impact of community coalitions on obesity

prevention

--The presence of anti-smoking community

coalitions has been associated with lower rates

of tobacco consumption

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

$103 million awarded to 61 states and

communities including state amp local government

agencies tribes amp territories amp state amp local non-

profit organizations

To build capacity to implement changes for

community prevention efforts to ensure long-

term success

To implement evidence-based and practice-

based programs to improve health amp wellness

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Priority areas are

Tobacco-free living

Active living and healthy eating

Evidence-based quality clinical and other

preventive health services for prevention

and control of high blood pressure and

high cholesterol

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Applicants proposed specific activities in

line with their chosen priority areas in their

applications

Grantee activities will not be finalized until

plans are negotiated with CDC by early

2012

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Capacity-Building Award

The Confederated Tribes of The Chehalis

Reservation is receiving a $498663 planning

award to build capacity to support healthy

lifestyles among their tribal population of 1500

in Washington State

Work will target tobacco-free living active living

and healthy eating and quality clinical and other

healthy serviceswwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Implementation Award

Austin TX Dept of Health and Human Services

is receiving $1026158 to serve Travis County

(Austin) to expand efforts in tobacco-free living

active living and healthy eating quality clinical

and other preventive services social and

emotional wellness and healthy and safe

physical environmentswwwcdcgov1052011

Building sustainable healthy

communities Bottom line

Obesity is an environmental problem

Despite progress in genetic research public health advances only will occur when we take the environment seriously

Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment

Until we do this we will not make substantial progress in addressing the epidemic of obesity

Poston amp Foreyt Atherosclerosis 1999

Whatrsquos the best approach

Integrate all sectors of society into community

change interventions

Incorporate

Science amp Technology

Education

FamilyCommunity

Healthcare

Arts amp Entertainment

Law amp Politics

Commerce amp Trade

Sectors of Society

Arts amp Entertainm

ent

Commerce amp Trade

Education

FamilyCommunity

Healthcare

Law amp Politics

Science amp Technology

Project FIT rationale design and baseline characteristics of a school- and community-

based intervention to address physical activity and healthy eating among low-income

elementary school children

Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D

Oh HJ Orth J Randall S Mayfield K Holmes D

Source

Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu

Abstract

BACKGROUND

This paper describes Project FIT a collaboration between the public school system local

health systems physicians neighborhood associations businesses faith-based leaders

community agencies and university researchers to develop a multi-faceted approach to

promote physical activity and healthy eating toward the general goal of preventing and

reducing childhood obesity among children in Grand Rapids MI USA

METHODSDESIGN

There are four overall components to Project FIT school community social marketing and

school staff wellness - all that focus on 1) increasing access to safe and affordable physical

activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)

improving the affordability and availability of nutritious food in the neighborhoods surrounding

the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding

nutrition and physical activity among school staff parents and students 4) impacting the

culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging

dialogue among all community partners to leverage existing programs and introduce new

ones

Reduction in Initial Weight by Gender

N=872

N=1229N=1197

N=830

-12

-10

-8

-6

-4

-2

0

0 2 4 6 8 10 12

Months

R

ed

uctio

n in

In

itia

l W

eig

ht

Men

Women

Plt0001

The Look AHEAD Research Group Diabetes Care 2007

Fitness Change () at 1-Year

0

5

10

15

20

25

Mean

Fitness C

hange

Unadjusted

Plt0001Adjusted for 1 Year

Weight Change Plt0001

58

209

108

159

DSE ILI ILIDSE

The Look AHEAD Research Group Diabetes Care 2007

1-Year Changes in Markers of

Diabetes Control

Markers of Diabetes

Control ILI DSE P-value

Hemoglobin A1c () BL

Hemoglobin A1c () Y1

Y1 ndash Baseline

725

661

-064

729

715

-014

026

lt0001

lt0001

Fasting glucose (mgdl) BL

Fasting glucose (mgdl) Y1

Y1 ndash Baseline

1519

1304

-215

1536

1464

-72

021

lt0001

lt0001

Diabetes medications BL

Diabetes medications Y1

Y1 ndash Baseline

865

786

-78

865

887

22

093

lt0001

lt0001

1-Year Changes in Markers of

Blood Pressure ControlMarkers of Blood Pressure

Control ILI DSE P-value

Systolic BP (mmHg) BL

Systolic BP (mmHg) Y1

Y1 ndash Baseline

1282

1214

-68

1294

1266

-28

026

lt0001

lt0001

Diastolic BP (mmHg) BL

Diastolic BP (mmHg) Y1

Y1 ndash Baseline

699

670

-30

704

686

-18

011

lt0001

lt0001

Antihypertensive medications BL

Antihypertensive medications Y1

Y1 ndash Baseline

753

752

-01

737

759

22

023

054

002

1-Year Changes in Markers of Lipid

Control

Markers of Lipid Control ILI DSE P-value

LDL-cholesterol (mgdl) BL

LDL-cholesterol (mgdl) Y1

Y1 ndash Baseline

1122

1070

-52

1124

1067

-57

078

074

049

HDL-cholesterol (mgdl) BL

HDL-cholesterol (mgdl) Y1

Y1 ndash Baseline

435

469

34

436

449

14

080

lt0001

lt0001

Triglycerides (mgdl) BL

Triglycerides (mgdl) Y1

Y1 ndash Baseline

1828

1525

-303

1800

1654

-146

038

lt0001

lt0001

Lipid lowering medications BL

Lipid lowering medications Y1

Y1 ndash Baseline

494

530

37

484

578

94

052

lt0001

lt0001

1-Year Changes in Percent of Participants

Meeting ADA Goals

ADA Goal ILI DSE P-value

Hemoglobin A1c lt 7 BL

Hemoglobin A1c lt 7 Y1

Y1 ndash Baseline

463

727

264

454

508

54

050

lt0001

lt0001

Blood pressure lt 13080 mmHg BL

Blood pressure lt 13080 mmHg Y1

Y1 ndash Baseline

535

686

151

499

570

70

001

lt0001

lt0001

LDL-cholesterol lt 100 mgdl BL

LDL-cholesterol lt 100 mgdl Y1

Y1 ndash Baseline

371

438

67

369

449

80

087

045

034

All three goals BL

All three goals Y1

Y1 ndash Baseline

108

236

128

95

160

65

013

lt0001

lt0001

Mean Changes in Weight Fitness amp BP

Averaged Over Four Years

DSE

Mean

ILI

Mean

P-value

Weight Loss

( initial wt)

-088 -615 lt 00001

Fitness

( METS)

196 1274 lt00001

HbA1c -009 -036 lt 00001

SBP (mm Hg) -297 -533 lt 00001

DBP (mm Hg) -248 -292 0012

Look AHEAD Research Group Arch Int Med 2010

Mean Changes in Lipid Profile

Averaged Over Four Years

DSE

Mean

ILI

Mean

P-value

HDL (mgdl) 197 367 lt00001

TG (mgdl) -1975 -2556 00006

LDL (mgdl) -1284 -1127 0009

LDL (mgdl)

(Adjusting for

medication use)

-922 -875 042

Look AHEAD Research Group Arch Int Med 2010

Percent () Completing Outcome

Measures at Years 1-4

Intervention Group

(ILI)

Year 1 971

Year 2 949

Year 3 940

Year 4 941

Comparison Group

(DSE)

Year 1 957

Year 2 935

Year 3 938

Year 4 931

Look AHEAD Summary

ILI had significantly greater improvements than DSE in all CVD risk factors averaged across 4 years (except LDL-C)

There may be long-term beneficial effects from this 4-year period in which ILI subjects have been exposed to lower CVD risk factors

Longer follow-ups will determine whether these lowered CVD risk factors can be maintained amp whether lifestyle intervention has positive effects on CVD morbidity amp mortality

Mary J

Female

White

56 years old at start of Look AHEAD

study

Past Medical History Type 2 diabetes

overweight diverticulosis arthritis

sleep apnea back pain

Mary J

bullLong term strugglesbull Helping youngest daughter with

personal issues and children

bull Rotator cuff problems

bull Degenerative disks in back

bull Rheumatoid arthritis

bull Diabetes

bull Physically demanding job

bull Financial struggles

Pounds

Years

82007 grandkids enter pre-school

Catherine L

Female

White

47 years old at start of Look AHEAD

study

Past Medical History Type 2 diabetes

overweight high blood pressure

hypothyroidism back pain

Catherine L

Long term struggles

bull Motherrsquos declining health and death

bull Multiple serious injuries

bull Sudden death of sister

bull Death of step-father

bull Declining economy

bull Children living at home

Pounds

Years

Realistic Management Goals

5-10 weight loss

Health energy and fitness

Well-being and self-esteem

Mood and appearance

Functional and recreational

activity

Key Elements

Focus on health and energy

Food and physical activity diaries

Gradual increase in physical activity

Gradual reduction in dietary fat

No feelings of food deprivation

Social support groups

Recommended Strategies for Building

Sustainable Healthy Communities

Overview from USA

Promote the availability of affordable healthy

food and beverages

Support healthy food and beverage choices

Encourage breastfeeding

Encourage physical activity or limit sedentary

activity among children amp youth

Create safe communities that support physical

activity

Encourage communities to organize for change

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Increase the availability of healthier food and

beverage choices in public service venues (eg

schools city amp county buildings etc)

--Insufficient evidence in school-based programs

--Associations suggest availability amp increased

consumption

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve availability of affordable healthier

food amp beverage choices in public service

venues

--Reducing the cost of healthier foods

increases their purchase

--Providing coupons redeemable for

healthier foods increases their purchase

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve geographic availability of

supermarkets in underserved areas

-- Greater access to nearby supermarkets is

associated with healthier eating behaviors

-- Increasing the number of supermarkets in

underserved neighborhoods increased

real estate values increased economic

activity amp employment amp resulted in lower

food prices

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Provide incentives to food retailers to locate in

andor offer healthier food choices in

underserved areas

-- Presence of retail venues that provide healthier

foods is associated with better nutrition

-- Greater availability of supermarkets was

associated with lower adolescent BMI scores

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Improve availability of mechanisms for

purchasing foods from farms

--Evidence supporting a direct link between

purchasing food from farms amp improved diet is

limited

--Two studies of initiatives to encourage

participation in farmersrsquo market showed

increased intention to eat more fruits amp

vegetables but no direct evidence

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Provide incentives for the production

distribution and procurement of foods from local

farms

--No evidence has been published to link local

food production amp health outcomes

--There is a current study exploring the potential

nutritional amp health benefits of eating locally

grown foods

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Restrict availability of less healthy foods amp

beverages in public service venues

--No peer-reviewed studies examined the impact

designed to restrict availability of less healthy

foods in public service venues

--21 states have policies that restrict the sale of

competitive foods in schools beyond USDA

regulations however no studies have evaluated

the impact of the policies

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Institute smaller portion size options in public

service venues

--Evidence is lacking to demonstrate effectiveness

of population-based interventions aimed at

reducing portion sizes in public service venues

--Evidence from clinical studies in laboratories

demonstrates decreasing portion sizes

decreases energy intake

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Limit advertisements of less healthy foods amp

beverages

--Little evidence is available regarding the impact

of restricting advertising on purchasing amp

consumption of less healthy foods

--Cross-sectional time-series studies of tobacco-

control efforts suggest an association between

advertising bans amp decreased tobacco

consumption

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Discourage consumption of sugar-sweetened

beverages

--One longitudinal study of a school-based

intervention among Native-American high school

students showed a substantial reduction in

sugar-sweetened beverages over a 3-year

period

--A RCT of a home-based intervention that

eliminated sugar-sweetened beverages showed

reduction in BMI scores

Recommended Community Strategies Strategies to encourage breastfeeding

Increase support for breastfeeding

--Evidence directly linking environmental

interventions that support breastfeeding with

obesity-related outcomes is lacking

--Epidemiologic studies indicate that breastfeeding

helps prevent pediatric obesity

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Require physical education in schools

--14 studies have demonstrated that school-based

PE was effective in increasing levels of physical

activity and improving physical fitness

--Minimum of 150 minwk in elementary schools

225 minwk in middle schools and high schools

throughout the school year as recommended by

NASPE

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Increase opportunities for extracurricular

physical activity

--Participation in after-school programs increased

studentsrsquo level of physical activity amp improved

obesity-related outcomes (improved CV fitness

reduced body fat)

--2 pilot studies providing extracurricular physical

activity showed increased levels of PA amp

decreased sedentary behavior

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Reduce screen time in public service venues

--A school-based RCT indicated that children who

reduced their television videotape amp video

game use had significant decrease in BMI tricep

skin fold thickness amp waist circumference

compared to controls

--Spending less time watching television is

associated with increased physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Improve access to outdoor recreational

facilities

--Review of 108 studies indicated that access to facilities

and programs for recreation near their homes amp time

spent outdoors correlated positively with increased

physical activity among childrenamp adults

--Perceptions that footpaths are safe for walking was

significantly associated with adults being classified as

physically active at a level sufficient for health benefits

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting

bicycling

--Longitudinal intervention studies have

demonstrated that improving bicycling

infrastructure is associated with increased

frequency of bicycling

--Cross-sectional studies indicated a significant

association between bicycling infrastructure amp

frequency of biking

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting walking

--Reviews of cross-sectional studies of

environmental correlates of physical activity amp

walking generally find a positive association

between infrastructure supportive of walking amp

physical activity

--Identifying amp creating safe routes to school

together with educational components

increased the number of students walking to

school

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Locating schools within easy walking

distance of residential areas

--Community-scale urban design amp land use policies amp

practices including locating schools stores workplaces

amp recreation areas close to residential areas are

effective in facilitating an increase in levels of physical

activity

--Majority of efforts to encourage walking to school involve

improving the routes rather than improving the location

of schools

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Improve access to public transportation

--Insufficient evidence exists to determine

effectiveness of transportation policies in

increasing the level of physical activity or

improving fitness

--1 study indicated that 29 of individuals who

walk to and from public transit achieve at least

30 minutes of daily physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Zone for mixed-use development

--Allows residential commercial institutional amp

other public land uses to be located in close

proximity to one another

--Studies using correlation analyses amp regression

models indicated that mixed land use was

associated with increased walking amp cycling

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance personal safety in areas where

persons are or could be physically active

--Cross-sectional studies have demonstrated a

negative relationship between crime rates andor

perceived safety amp physical activity in

neighborhoods

--Few intervention studies have evaluated the

impact of policies amp practices to improve

personal safety on physical activity

Geospatial Mapping Linking Urban

Environments to Health Risk

Measure association between environmental variables amp health risk factors

Assess relationships between variables at different levels of analysis

Used in conjunction with linear analyses

Our Community Environmental Model

of Obesity

Community Factors

Poverty

Crime

Grocery Quality

Restaurants

Parks

Sidewalks

Fast Food Outlets

Recreational

Facilities

Individual Factors

Dietary Intake

Physical Activity

Genetics

Family History

StressCoping

Eating Disorders

Psychological

Problems

Weight

Status

Chosen Neighborhoods

Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped

We then matched census-block groups within the income groups by population density and percentage of minority representation

One matched block group per income level was randomly selected

Prevalence of Obesity in

Block-Groups

0

5

10

15

20

25

30

35

40

45

50

Ag

e-a

dju

sted

Ob

esit

y P

rev

ale

nce

(

)

High-Income Low-Income

Age-standardized to the 1990 US Census

Density of Environmental Factors in the

Community Contributes to a ldquoToxicrdquo

Obesity Environment

0

2

4

6

8

10

12

14

16

18

Fast-food Convenience Store Bars

Den

sity

10

00

perso

ns

High-Income Low-Income

COMMUNITYrsquoS PERCEPTION OF SAFETY

0

5

10

15

20

25

30

35

40

Daytime Nighttime

Perc

en

t (

) F

eeli

ng

So

mew

hat

Safe

or

Un

safe

Low-Income High-Income

Percent Substandard (or worse) Housing

or Ground Conditions

of Residential Properties

0

10

20

30

Structural Grounds

Perc

en

t (

)

Low-Income High-Income

CONCLUSIONS

These data suggest that the higher

frequency of outlets providing

calorically-dense foods and alcohol may

contribute to greater obesity prevalence

in residents of low-income communities

More research is needed to thoroughly

document environmental determinants

of health and obesity

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

From 1994-1998 HUD randomly assigned

4498 women with children living in public

housing in high-poverty urban census

tracts to one of three groups (1) housing

vouchers redeemable only if they moved

to a low-poverty census tract (2)

unrestricted vouchers or (3) control group

(no vouchers)

Ludwig et al NEJM 201136516

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

10-12 year follow-up showed modest but

potentially important reductions in the

prevalence of extreme obesity amp diabetes in the

group moving from a neighborhood with high

poverty on one of low poverty compared to the

control group

No differences between the group receiving

traditional vouchers amp the control group

ldquoNeighborhoods matterrdquo

Ludwig et al NEJM 201136516

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance traffic safety in areas where

persons are or could be physically active

--Community-scale urban design amp land use policies to

promote physical activity including design components

to improve street lighting infrastructure projects to

increase safety of pedestrian street crossing and use of

traffic calming approaches such as speed humps amp

traffic circles are effective in increasing physical activity

--Both community-scale amp street-scale policies amp practices

are effective in increasing physical activity

Recommended Community Strategies Encourage Communities to Organize for Change

Participate in community coalitions or

partnerships to address obesity

--Little evidence is available to determine the

impact of community coalitions on obesity

prevention

--The presence of anti-smoking community

coalitions has been associated with lower rates

of tobacco consumption

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

$103 million awarded to 61 states and

communities including state amp local government

agencies tribes amp territories amp state amp local non-

profit organizations

To build capacity to implement changes for

community prevention efforts to ensure long-

term success

To implement evidence-based and practice-

based programs to improve health amp wellness

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Priority areas are

Tobacco-free living

Active living and healthy eating

Evidence-based quality clinical and other

preventive health services for prevention

and control of high blood pressure and

high cholesterol

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Applicants proposed specific activities in

line with their chosen priority areas in their

applications

Grantee activities will not be finalized until

plans are negotiated with CDC by early

2012

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Capacity-Building Award

The Confederated Tribes of The Chehalis

Reservation is receiving a $498663 planning

award to build capacity to support healthy

lifestyles among their tribal population of 1500

in Washington State

Work will target tobacco-free living active living

and healthy eating and quality clinical and other

healthy serviceswwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Implementation Award

Austin TX Dept of Health and Human Services

is receiving $1026158 to serve Travis County

(Austin) to expand efforts in tobacco-free living

active living and healthy eating quality clinical

and other preventive services social and

emotional wellness and healthy and safe

physical environmentswwwcdcgov1052011

Building sustainable healthy

communities Bottom line

Obesity is an environmental problem

Despite progress in genetic research public health advances only will occur when we take the environment seriously

Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment

Until we do this we will not make substantial progress in addressing the epidemic of obesity

Poston amp Foreyt Atherosclerosis 1999

Whatrsquos the best approach

Integrate all sectors of society into community

change interventions

Incorporate

Science amp Technology

Education

FamilyCommunity

Healthcare

Arts amp Entertainment

Law amp Politics

Commerce amp Trade

Sectors of Society

Arts amp Entertainm

ent

Commerce amp Trade

Education

FamilyCommunity

Healthcare

Law amp Politics

Science amp Technology

Project FIT rationale design and baseline characteristics of a school- and community-

based intervention to address physical activity and healthy eating among low-income

elementary school children

Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D

Oh HJ Orth J Randall S Mayfield K Holmes D

Source

Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu

Abstract

BACKGROUND

This paper describes Project FIT a collaboration between the public school system local

health systems physicians neighborhood associations businesses faith-based leaders

community agencies and university researchers to develop a multi-faceted approach to

promote physical activity and healthy eating toward the general goal of preventing and

reducing childhood obesity among children in Grand Rapids MI USA

METHODSDESIGN

There are four overall components to Project FIT school community social marketing and

school staff wellness - all that focus on 1) increasing access to safe and affordable physical

activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)

improving the affordability and availability of nutritious food in the neighborhoods surrounding

the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding

nutrition and physical activity among school staff parents and students 4) impacting the

culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging

dialogue among all community partners to leverage existing programs and introduce new

ones

Fitness Change () at 1-Year

0

5

10

15

20

25

Mean

Fitness C

hange

Unadjusted

Plt0001Adjusted for 1 Year

Weight Change Plt0001

58

209

108

159

DSE ILI ILIDSE

The Look AHEAD Research Group Diabetes Care 2007

1-Year Changes in Markers of

Diabetes Control

Markers of Diabetes

Control ILI DSE P-value

Hemoglobin A1c () BL

Hemoglobin A1c () Y1

Y1 ndash Baseline

725

661

-064

729

715

-014

026

lt0001

lt0001

Fasting glucose (mgdl) BL

Fasting glucose (mgdl) Y1

Y1 ndash Baseline

1519

1304

-215

1536

1464

-72

021

lt0001

lt0001

Diabetes medications BL

Diabetes medications Y1

Y1 ndash Baseline

865

786

-78

865

887

22

093

lt0001

lt0001

1-Year Changes in Markers of

Blood Pressure ControlMarkers of Blood Pressure

Control ILI DSE P-value

Systolic BP (mmHg) BL

Systolic BP (mmHg) Y1

Y1 ndash Baseline

1282

1214

-68

1294

1266

-28

026

lt0001

lt0001

Diastolic BP (mmHg) BL

Diastolic BP (mmHg) Y1

Y1 ndash Baseline

699

670

-30

704

686

-18

011

lt0001

lt0001

Antihypertensive medications BL

Antihypertensive medications Y1

Y1 ndash Baseline

753

752

-01

737

759

22

023

054

002

1-Year Changes in Markers of Lipid

Control

Markers of Lipid Control ILI DSE P-value

LDL-cholesterol (mgdl) BL

LDL-cholesterol (mgdl) Y1

Y1 ndash Baseline

1122

1070

-52

1124

1067

-57

078

074

049

HDL-cholesterol (mgdl) BL

HDL-cholesterol (mgdl) Y1

Y1 ndash Baseline

435

469

34

436

449

14

080

lt0001

lt0001

Triglycerides (mgdl) BL

Triglycerides (mgdl) Y1

Y1 ndash Baseline

1828

1525

-303

1800

1654

-146

038

lt0001

lt0001

Lipid lowering medications BL

Lipid lowering medications Y1

Y1 ndash Baseline

494

530

37

484

578

94

052

lt0001

lt0001

1-Year Changes in Percent of Participants

Meeting ADA Goals

ADA Goal ILI DSE P-value

Hemoglobin A1c lt 7 BL

Hemoglobin A1c lt 7 Y1

Y1 ndash Baseline

463

727

264

454

508

54

050

lt0001

lt0001

Blood pressure lt 13080 mmHg BL

Blood pressure lt 13080 mmHg Y1

Y1 ndash Baseline

535

686

151

499

570

70

001

lt0001

lt0001

LDL-cholesterol lt 100 mgdl BL

LDL-cholesterol lt 100 mgdl Y1

Y1 ndash Baseline

371

438

67

369

449

80

087

045

034

All three goals BL

All three goals Y1

Y1 ndash Baseline

108

236

128

95

160

65

013

lt0001

lt0001

Mean Changes in Weight Fitness amp BP

Averaged Over Four Years

DSE

Mean

ILI

Mean

P-value

Weight Loss

( initial wt)

-088 -615 lt 00001

Fitness

( METS)

196 1274 lt00001

HbA1c -009 -036 lt 00001

SBP (mm Hg) -297 -533 lt 00001

DBP (mm Hg) -248 -292 0012

Look AHEAD Research Group Arch Int Med 2010

Mean Changes in Lipid Profile

Averaged Over Four Years

DSE

Mean

ILI

Mean

P-value

HDL (mgdl) 197 367 lt00001

TG (mgdl) -1975 -2556 00006

LDL (mgdl) -1284 -1127 0009

LDL (mgdl)

(Adjusting for

medication use)

-922 -875 042

Look AHEAD Research Group Arch Int Med 2010

Percent () Completing Outcome

Measures at Years 1-4

Intervention Group

(ILI)

Year 1 971

Year 2 949

Year 3 940

Year 4 941

Comparison Group

(DSE)

Year 1 957

Year 2 935

Year 3 938

Year 4 931

Look AHEAD Summary

ILI had significantly greater improvements than DSE in all CVD risk factors averaged across 4 years (except LDL-C)

There may be long-term beneficial effects from this 4-year period in which ILI subjects have been exposed to lower CVD risk factors

Longer follow-ups will determine whether these lowered CVD risk factors can be maintained amp whether lifestyle intervention has positive effects on CVD morbidity amp mortality

Mary J

Female

White

56 years old at start of Look AHEAD

study

Past Medical History Type 2 diabetes

overweight diverticulosis arthritis

sleep apnea back pain

Mary J

bullLong term strugglesbull Helping youngest daughter with

personal issues and children

bull Rotator cuff problems

bull Degenerative disks in back

bull Rheumatoid arthritis

bull Diabetes

bull Physically demanding job

bull Financial struggles

Pounds

Years

82007 grandkids enter pre-school

Catherine L

Female

White

47 years old at start of Look AHEAD

study

Past Medical History Type 2 diabetes

overweight high blood pressure

hypothyroidism back pain

Catherine L

Long term struggles

bull Motherrsquos declining health and death

bull Multiple serious injuries

bull Sudden death of sister

bull Death of step-father

bull Declining economy

bull Children living at home

Pounds

Years

Realistic Management Goals

5-10 weight loss

Health energy and fitness

Well-being and self-esteem

Mood and appearance

Functional and recreational

activity

Key Elements

Focus on health and energy

Food and physical activity diaries

Gradual increase in physical activity

Gradual reduction in dietary fat

No feelings of food deprivation

Social support groups

Recommended Strategies for Building

Sustainable Healthy Communities

Overview from USA

Promote the availability of affordable healthy

food and beverages

Support healthy food and beverage choices

Encourage breastfeeding

Encourage physical activity or limit sedentary

activity among children amp youth

Create safe communities that support physical

activity

Encourage communities to organize for change

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Increase the availability of healthier food and

beverage choices in public service venues (eg

schools city amp county buildings etc)

--Insufficient evidence in school-based programs

--Associations suggest availability amp increased

consumption

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve availability of affordable healthier

food amp beverage choices in public service

venues

--Reducing the cost of healthier foods

increases their purchase

--Providing coupons redeemable for

healthier foods increases their purchase

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve geographic availability of

supermarkets in underserved areas

-- Greater access to nearby supermarkets is

associated with healthier eating behaviors

-- Increasing the number of supermarkets in

underserved neighborhoods increased

real estate values increased economic

activity amp employment amp resulted in lower

food prices

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Provide incentives to food retailers to locate in

andor offer healthier food choices in

underserved areas

-- Presence of retail venues that provide healthier

foods is associated with better nutrition

-- Greater availability of supermarkets was

associated with lower adolescent BMI scores

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Improve availability of mechanisms for

purchasing foods from farms

--Evidence supporting a direct link between

purchasing food from farms amp improved diet is

limited

--Two studies of initiatives to encourage

participation in farmersrsquo market showed

increased intention to eat more fruits amp

vegetables but no direct evidence

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Provide incentives for the production

distribution and procurement of foods from local

farms

--No evidence has been published to link local

food production amp health outcomes

--There is a current study exploring the potential

nutritional amp health benefits of eating locally

grown foods

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Restrict availability of less healthy foods amp

beverages in public service venues

--No peer-reviewed studies examined the impact

designed to restrict availability of less healthy

foods in public service venues

--21 states have policies that restrict the sale of

competitive foods in schools beyond USDA

regulations however no studies have evaluated

the impact of the policies

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Institute smaller portion size options in public

service venues

--Evidence is lacking to demonstrate effectiveness

of population-based interventions aimed at

reducing portion sizes in public service venues

--Evidence from clinical studies in laboratories

demonstrates decreasing portion sizes

decreases energy intake

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Limit advertisements of less healthy foods amp

beverages

--Little evidence is available regarding the impact

of restricting advertising on purchasing amp

consumption of less healthy foods

--Cross-sectional time-series studies of tobacco-

control efforts suggest an association between

advertising bans amp decreased tobacco

consumption

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Discourage consumption of sugar-sweetened

beverages

--One longitudinal study of a school-based

intervention among Native-American high school

students showed a substantial reduction in

sugar-sweetened beverages over a 3-year

period

--A RCT of a home-based intervention that

eliminated sugar-sweetened beverages showed

reduction in BMI scores

Recommended Community Strategies Strategies to encourage breastfeeding

Increase support for breastfeeding

--Evidence directly linking environmental

interventions that support breastfeeding with

obesity-related outcomes is lacking

--Epidemiologic studies indicate that breastfeeding

helps prevent pediatric obesity

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Require physical education in schools

--14 studies have demonstrated that school-based

PE was effective in increasing levels of physical

activity and improving physical fitness

--Minimum of 150 minwk in elementary schools

225 minwk in middle schools and high schools

throughout the school year as recommended by

NASPE

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Increase opportunities for extracurricular

physical activity

--Participation in after-school programs increased

studentsrsquo level of physical activity amp improved

obesity-related outcomes (improved CV fitness

reduced body fat)

--2 pilot studies providing extracurricular physical

activity showed increased levels of PA amp

decreased sedentary behavior

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Reduce screen time in public service venues

--A school-based RCT indicated that children who

reduced their television videotape amp video

game use had significant decrease in BMI tricep

skin fold thickness amp waist circumference

compared to controls

--Spending less time watching television is

associated with increased physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Improve access to outdoor recreational

facilities

--Review of 108 studies indicated that access to facilities

and programs for recreation near their homes amp time

spent outdoors correlated positively with increased

physical activity among childrenamp adults

--Perceptions that footpaths are safe for walking was

significantly associated with adults being classified as

physically active at a level sufficient for health benefits

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting

bicycling

--Longitudinal intervention studies have

demonstrated that improving bicycling

infrastructure is associated with increased

frequency of bicycling

--Cross-sectional studies indicated a significant

association between bicycling infrastructure amp

frequency of biking

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting walking

--Reviews of cross-sectional studies of

environmental correlates of physical activity amp

walking generally find a positive association

between infrastructure supportive of walking amp

physical activity

--Identifying amp creating safe routes to school

together with educational components

increased the number of students walking to

school

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Locating schools within easy walking

distance of residential areas

--Community-scale urban design amp land use policies amp

practices including locating schools stores workplaces

amp recreation areas close to residential areas are

effective in facilitating an increase in levels of physical

activity

--Majority of efforts to encourage walking to school involve

improving the routes rather than improving the location

of schools

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Improve access to public transportation

--Insufficient evidence exists to determine

effectiveness of transportation policies in

increasing the level of physical activity or

improving fitness

--1 study indicated that 29 of individuals who

walk to and from public transit achieve at least

30 minutes of daily physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Zone for mixed-use development

--Allows residential commercial institutional amp

other public land uses to be located in close

proximity to one another

--Studies using correlation analyses amp regression

models indicated that mixed land use was

associated with increased walking amp cycling

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance personal safety in areas where

persons are or could be physically active

--Cross-sectional studies have demonstrated a

negative relationship between crime rates andor

perceived safety amp physical activity in

neighborhoods

--Few intervention studies have evaluated the

impact of policies amp practices to improve

personal safety on physical activity

Geospatial Mapping Linking Urban

Environments to Health Risk

Measure association between environmental variables amp health risk factors

Assess relationships between variables at different levels of analysis

Used in conjunction with linear analyses

Our Community Environmental Model

of Obesity

Community Factors

Poverty

Crime

Grocery Quality

Restaurants

Parks

Sidewalks

Fast Food Outlets

Recreational

Facilities

Individual Factors

Dietary Intake

Physical Activity

Genetics

Family History

StressCoping

Eating Disorders

Psychological

Problems

Weight

Status

Chosen Neighborhoods

Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped

We then matched census-block groups within the income groups by population density and percentage of minority representation

One matched block group per income level was randomly selected

Prevalence of Obesity in

Block-Groups

0

5

10

15

20

25

30

35

40

45

50

Ag

e-a

dju

sted

Ob

esit

y P

rev

ale

nce

(

)

High-Income Low-Income

Age-standardized to the 1990 US Census

Density of Environmental Factors in the

Community Contributes to a ldquoToxicrdquo

Obesity Environment

0

2

4

6

8

10

12

14

16

18

Fast-food Convenience Store Bars

Den

sity

10

00

perso

ns

High-Income Low-Income

COMMUNITYrsquoS PERCEPTION OF SAFETY

0

5

10

15

20

25

30

35

40

Daytime Nighttime

Perc

en

t (

) F

eeli

ng

So

mew

hat

Safe

or

Un

safe

Low-Income High-Income

Percent Substandard (or worse) Housing

or Ground Conditions

of Residential Properties

0

10

20

30

Structural Grounds

Perc

en

t (

)

Low-Income High-Income

CONCLUSIONS

These data suggest that the higher

frequency of outlets providing

calorically-dense foods and alcohol may

contribute to greater obesity prevalence

in residents of low-income communities

More research is needed to thoroughly

document environmental determinants

of health and obesity

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

From 1994-1998 HUD randomly assigned

4498 women with children living in public

housing in high-poverty urban census

tracts to one of three groups (1) housing

vouchers redeemable only if they moved

to a low-poverty census tract (2)

unrestricted vouchers or (3) control group

(no vouchers)

Ludwig et al NEJM 201136516

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

10-12 year follow-up showed modest but

potentially important reductions in the

prevalence of extreme obesity amp diabetes in the

group moving from a neighborhood with high

poverty on one of low poverty compared to the

control group

No differences between the group receiving

traditional vouchers amp the control group

ldquoNeighborhoods matterrdquo

Ludwig et al NEJM 201136516

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance traffic safety in areas where

persons are or could be physically active

--Community-scale urban design amp land use policies to

promote physical activity including design components

to improve street lighting infrastructure projects to

increase safety of pedestrian street crossing and use of

traffic calming approaches such as speed humps amp

traffic circles are effective in increasing physical activity

--Both community-scale amp street-scale policies amp practices

are effective in increasing physical activity

Recommended Community Strategies Encourage Communities to Organize for Change

Participate in community coalitions or

partnerships to address obesity

--Little evidence is available to determine the

impact of community coalitions on obesity

prevention

--The presence of anti-smoking community

coalitions has been associated with lower rates

of tobacco consumption

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

$103 million awarded to 61 states and

communities including state amp local government

agencies tribes amp territories amp state amp local non-

profit organizations

To build capacity to implement changes for

community prevention efforts to ensure long-

term success

To implement evidence-based and practice-

based programs to improve health amp wellness

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Priority areas are

Tobacco-free living

Active living and healthy eating

Evidence-based quality clinical and other

preventive health services for prevention

and control of high blood pressure and

high cholesterol

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Applicants proposed specific activities in

line with their chosen priority areas in their

applications

Grantee activities will not be finalized until

plans are negotiated with CDC by early

2012

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Capacity-Building Award

The Confederated Tribes of The Chehalis

Reservation is receiving a $498663 planning

award to build capacity to support healthy

lifestyles among their tribal population of 1500

in Washington State

Work will target tobacco-free living active living

and healthy eating and quality clinical and other

healthy serviceswwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Implementation Award

Austin TX Dept of Health and Human Services

is receiving $1026158 to serve Travis County

(Austin) to expand efforts in tobacco-free living

active living and healthy eating quality clinical

and other preventive services social and

emotional wellness and healthy and safe

physical environmentswwwcdcgov1052011

Building sustainable healthy

communities Bottom line

Obesity is an environmental problem

Despite progress in genetic research public health advances only will occur when we take the environment seriously

Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment

Until we do this we will not make substantial progress in addressing the epidemic of obesity

Poston amp Foreyt Atherosclerosis 1999

Whatrsquos the best approach

Integrate all sectors of society into community

change interventions

Incorporate

Science amp Technology

Education

FamilyCommunity

Healthcare

Arts amp Entertainment

Law amp Politics

Commerce amp Trade

Sectors of Society

Arts amp Entertainm

ent

Commerce amp Trade

Education

FamilyCommunity

Healthcare

Law amp Politics

Science amp Technology

Project FIT rationale design and baseline characteristics of a school- and community-

based intervention to address physical activity and healthy eating among low-income

elementary school children

Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D

Oh HJ Orth J Randall S Mayfield K Holmes D

Source

Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu

Abstract

BACKGROUND

This paper describes Project FIT a collaboration between the public school system local

health systems physicians neighborhood associations businesses faith-based leaders

community agencies and university researchers to develop a multi-faceted approach to

promote physical activity and healthy eating toward the general goal of preventing and

reducing childhood obesity among children in Grand Rapids MI USA

METHODSDESIGN

There are four overall components to Project FIT school community social marketing and

school staff wellness - all that focus on 1) increasing access to safe and affordable physical

activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)

improving the affordability and availability of nutritious food in the neighborhoods surrounding

the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding

nutrition and physical activity among school staff parents and students 4) impacting the

culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging

dialogue among all community partners to leverage existing programs and introduce new

ones

1-Year Changes in Markers of

Diabetes Control

Markers of Diabetes

Control ILI DSE P-value

Hemoglobin A1c () BL

Hemoglobin A1c () Y1

Y1 ndash Baseline

725

661

-064

729

715

-014

026

lt0001

lt0001

Fasting glucose (mgdl) BL

Fasting glucose (mgdl) Y1

Y1 ndash Baseline

1519

1304

-215

1536

1464

-72

021

lt0001

lt0001

Diabetes medications BL

Diabetes medications Y1

Y1 ndash Baseline

865

786

-78

865

887

22

093

lt0001

lt0001

1-Year Changes in Markers of

Blood Pressure ControlMarkers of Blood Pressure

Control ILI DSE P-value

Systolic BP (mmHg) BL

Systolic BP (mmHg) Y1

Y1 ndash Baseline

1282

1214

-68

1294

1266

-28

026

lt0001

lt0001

Diastolic BP (mmHg) BL

Diastolic BP (mmHg) Y1

Y1 ndash Baseline

699

670

-30

704

686

-18

011

lt0001

lt0001

Antihypertensive medications BL

Antihypertensive medications Y1

Y1 ndash Baseline

753

752

-01

737

759

22

023

054

002

1-Year Changes in Markers of Lipid

Control

Markers of Lipid Control ILI DSE P-value

LDL-cholesterol (mgdl) BL

LDL-cholesterol (mgdl) Y1

Y1 ndash Baseline

1122

1070

-52

1124

1067

-57

078

074

049

HDL-cholesterol (mgdl) BL

HDL-cholesterol (mgdl) Y1

Y1 ndash Baseline

435

469

34

436

449

14

080

lt0001

lt0001

Triglycerides (mgdl) BL

Triglycerides (mgdl) Y1

Y1 ndash Baseline

1828

1525

-303

1800

1654

-146

038

lt0001

lt0001

Lipid lowering medications BL

Lipid lowering medications Y1

Y1 ndash Baseline

494

530

37

484

578

94

052

lt0001

lt0001

1-Year Changes in Percent of Participants

Meeting ADA Goals

ADA Goal ILI DSE P-value

Hemoglobin A1c lt 7 BL

Hemoglobin A1c lt 7 Y1

Y1 ndash Baseline

463

727

264

454

508

54

050

lt0001

lt0001

Blood pressure lt 13080 mmHg BL

Blood pressure lt 13080 mmHg Y1

Y1 ndash Baseline

535

686

151

499

570

70

001

lt0001

lt0001

LDL-cholesterol lt 100 mgdl BL

LDL-cholesterol lt 100 mgdl Y1

Y1 ndash Baseline

371

438

67

369

449

80

087

045

034

All three goals BL

All three goals Y1

Y1 ndash Baseline

108

236

128

95

160

65

013

lt0001

lt0001

Mean Changes in Weight Fitness amp BP

Averaged Over Four Years

DSE

Mean

ILI

Mean

P-value

Weight Loss

( initial wt)

-088 -615 lt 00001

Fitness

( METS)

196 1274 lt00001

HbA1c -009 -036 lt 00001

SBP (mm Hg) -297 -533 lt 00001

DBP (mm Hg) -248 -292 0012

Look AHEAD Research Group Arch Int Med 2010

Mean Changes in Lipid Profile

Averaged Over Four Years

DSE

Mean

ILI

Mean

P-value

HDL (mgdl) 197 367 lt00001

TG (mgdl) -1975 -2556 00006

LDL (mgdl) -1284 -1127 0009

LDL (mgdl)

(Adjusting for

medication use)

-922 -875 042

Look AHEAD Research Group Arch Int Med 2010

Percent () Completing Outcome

Measures at Years 1-4

Intervention Group

(ILI)

Year 1 971

Year 2 949

Year 3 940

Year 4 941

Comparison Group

(DSE)

Year 1 957

Year 2 935

Year 3 938

Year 4 931

Look AHEAD Summary

ILI had significantly greater improvements than DSE in all CVD risk factors averaged across 4 years (except LDL-C)

There may be long-term beneficial effects from this 4-year period in which ILI subjects have been exposed to lower CVD risk factors

Longer follow-ups will determine whether these lowered CVD risk factors can be maintained amp whether lifestyle intervention has positive effects on CVD morbidity amp mortality

Mary J

Female

White

56 years old at start of Look AHEAD

study

Past Medical History Type 2 diabetes

overweight diverticulosis arthritis

sleep apnea back pain

Mary J

bullLong term strugglesbull Helping youngest daughter with

personal issues and children

bull Rotator cuff problems

bull Degenerative disks in back

bull Rheumatoid arthritis

bull Diabetes

bull Physically demanding job

bull Financial struggles

Pounds

Years

82007 grandkids enter pre-school

Catherine L

Female

White

47 years old at start of Look AHEAD

study

Past Medical History Type 2 diabetes

overweight high blood pressure

hypothyroidism back pain

Catherine L

Long term struggles

bull Motherrsquos declining health and death

bull Multiple serious injuries

bull Sudden death of sister

bull Death of step-father

bull Declining economy

bull Children living at home

Pounds

Years

Realistic Management Goals

5-10 weight loss

Health energy and fitness

Well-being and self-esteem

Mood and appearance

Functional and recreational

activity

Key Elements

Focus on health and energy

Food and physical activity diaries

Gradual increase in physical activity

Gradual reduction in dietary fat

No feelings of food deprivation

Social support groups

Recommended Strategies for Building

Sustainable Healthy Communities

Overview from USA

Promote the availability of affordable healthy

food and beverages

Support healthy food and beverage choices

Encourage breastfeeding

Encourage physical activity or limit sedentary

activity among children amp youth

Create safe communities that support physical

activity

Encourage communities to organize for change

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Increase the availability of healthier food and

beverage choices in public service venues (eg

schools city amp county buildings etc)

--Insufficient evidence in school-based programs

--Associations suggest availability amp increased

consumption

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve availability of affordable healthier

food amp beverage choices in public service

venues

--Reducing the cost of healthier foods

increases their purchase

--Providing coupons redeemable for

healthier foods increases their purchase

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve geographic availability of

supermarkets in underserved areas

-- Greater access to nearby supermarkets is

associated with healthier eating behaviors

-- Increasing the number of supermarkets in

underserved neighborhoods increased

real estate values increased economic

activity amp employment amp resulted in lower

food prices

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Provide incentives to food retailers to locate in

andor offer healthier food choices in

underserved areas

-- Presence of retail venues that provide healthier

foods is associated with better nutrition

-- Greater availability of supermarkets was

associated with lower adolescent BMI scores

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Improve availability of mechanisms for

purchasing foods from farms

--Evidence supporting a direct link between

purchasing food from farms amp improved diet is

limited

--Two studies of initiatives to encourage

participation in farmersrsquo market showed

increased intention to eat more fruits amp

vegetables but no direct evidence

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Provide incentives for the production

distribution and procurement of foods from local

farms

--No evidence has been published to link local

food production amp health outcomes

--There is a current study exploring the potential

nutritional amp health benefits of eating locally

grown foods

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Restrict availability of less healthy foods amp

beverages in public service venues

--No peer-reviewed studies examined the impact

designed to restrict availability of less healthy

foods in public service venues

--21 states have policies that restrict the sale of

competitive foods in schools beyond USDA

regulations however no studies have evaluated

the impact of the policies

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Institute smaller portion size options in public

service venues

--Evidence is lacking to demonstrate effectiveness

of population-based interventions aimed at

reducing portion sizes in public service venues

--Evidence from clinical studies in laboratories

demonstrates decreasing portion sizes

decreases energy intake

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Limit advertisements of less healthy foods amp

beverages

--Little evidence is available regarding the impact

of restricting advertising on purchasing amp

consumption of less healthy foods

--Cross-sectional time-series studies of tobacco-

control efforts suggest an association between

advertising bans amp decreased tobacco

consumption

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Discourage consumption of sugar-sweetened

beverages

--One longitudinal study of a school-based

intervention among Native-American high school

students showed a substantial reduction in

sugar-sweetened beverages over a 3-year

period

--A RCT of a home-based intervention that

eliminated sugar-sweetened beverages showed

reduction in BMI scores

Recommended Community Strategies Strategies to encourage breastfeeding

Increase support for breastfeeding

--Evidence directly linking environmental

interventions that support breastfeeding with

obesity-related outcomes is lacking

--Epidemiologic studies indicate that breastfeeding

helps prevent pediatric obesity

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Require physical education in schools

--14 studies have demonstrated that school-based

PE was effective in increasing levels of physical

activity and improving physical fitness

--Minimum of 150 minwk in elementary schools

225 minwk in middle schools and high schools

throughout the school year as recommended by

NASPE

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Increase opportunities for extracurricular

physical activity

--Participation in after-school programs increased

studentsrsquo level of physical activity amp improved

obesity-related outcomes (improved CV fitness

reduced body fat)

--2 pilot studies providing extracurricular physical

activity showed increased levels of PA amp

decreased sedentary behavior

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Reduce screen time in public service venues

--A school-based RCT indicated that children who

reduced their television videotape amp video

game use had significant decrease in BMI tricep

skin fold thickness amp waist circumference

compared to controls

--Spending less time watching television is

associated with increased physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Improve access to outdoor recreational

facilities

--Review of 108 studies indicated that access to facilities

and programs for recreation near their homes amp time

spent outdoors correlated positively with increased

physical activity among childrenamp adults

--Perceptions that footpaths are safe for walking was

significantly associated with adults being classified as

physically active at a level sufficient for health benefits

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting

bicycling

--Longitudinal intervention studies have

demonstrated that improving bicycling

infrastructure is associated with increased

frequency of bicycling

--Cross-sectional studies indicated a significant

association between bicycling infrastructure amp

frequency of biking

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting walking

--Reviews of cross-sectional studies of

environmental correlates of physical activity amp

walking generally find a positive association

between infrastructure supportive of walking amp

physical activity

--Identifying amp creating safe routes to school

together with educational components

increased the number of students walking to

school

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Locating schools within easy walking

distance of residential areas

--Community-scale urban design amp land use policies amp

practices including locating schools stores workplaces

amp recreation areas close to residential areas are

effective in facilitating an increase in levels of physical

activity

--Majority of efforts to encourage walking to school involve

improving the routes rather than improving the location

of schools

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Improve access to public transportation

--Insufficient evidence exists to determine

effectiveness of transportation policies in

increasing the level of physical activity or

improving fitness

--1 study indicated that 29 of individuals who

walk to and from public transit achieve at least

30 minutes of daily physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Zone for mixed-use development

--Allows residential commercial institutional amp

other public land uses to be located in close

proximity to one another

--Studies using correlation analyses amp regression

models indicated that mixed land use was

associated with increased walking amp cycling

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance personal safety in areas where

persons are or could be physically active

--Cross-sectional studies have demonstrated a

negative relationship between crime rates andor

perceived safety amp physical activity in

neighborhoods

--Few intervention studies have evaluated the

impact of policies amp practices to improve

personal safety on physical activity

Geospatial Mapping Linking Urban

Environments to Health Risk

Measure association between environmental variables amp health risk factors

Assess relationships between variables at different levels of analysis

Used in conjunction with linear analyses

Our Community Environmental Model

of Obesity

Community Factors

Poverty

Crime

Grocery Quality

Restaurants

Parks

Sidewalks

Fast Food Outlets

Recreational

Facilities

Individual Factors

Dietary Intake

Physical Activity

Genetics

Family History

StressCoping

Eating Disorders

Psychological

Problems

Weight

Status

Chosen Neighborhoods

Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped

We then matched census-block groups within the income groups by population density and percentage of minority representation

One matched block group per income level was randomly selected

Prevalence of Obesity in

Block-Groups

0

5

10

15

20

25

30

35

40

45

50

Ag

e-a

dju

sted

Ob

esit

y P

rev

ale

nce

(

)

High-Income Low-Income

Age-standardized to the 1990 US Census

Density of Environmental Factors in the

Community Contributes to a ldquoToxicrdquo

Obesity Environment

0

2

4

6

8

10

12

14

16

18

Fast-food Convenience Store Bars

Den

sity

10

00

perso

ns

High-Income Low-Income

COMMUNITYrsquoS PERCEPTION OF SAFETY

0

5

10

15

20

25

30

35

40

Daytime Nighttime

Perc

en

t (

) F

eeli

ng

So

mew

hat

Safe

or

Un

safe

Low-Income High-Income

Percent Substandard (or worse) Housing

or Ground Conditions

of Residential Properties

0

10

20

30

Structural Grounds

Perc

en

t (

)

Low-Income High-Income

CONCLUSIONS

These data suggest that the higher

frequency of outlets providing

calorically-dense foods and alcohol may

contribute to greater obesity prevalence

in residents of low-income communities

More research is needed to thoroughly

document environmental determinants

of health and obesity

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

From 1994-1998 HUD randomly assigned

4498 women with children living in public

housing in high-poverty urban census

tracts to one of three groups (1) housing

vouchers redeemable only if they moved

to a low-poverty census tract (2)

unrestricted vouchers or (3) control group

(no vouchers)

Ludwig et al NEJM 201136516

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

10-12 year follow-up showed modest but

potentially important reductions in the

prevalence of extreme obesity amp diabetes in the

group moving from a neighborhood with high

poverty on one of low poverty compared to the

control group

No differences between the group receiving

traditional vouchers amp the control group

ldquoNeighborhoods matterrdquo

Ludwig et al NEJM 201136516

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance traffic safety in areas where

persons are or could be physically active

--Community-scale urban design amp land use policies to

promote physical activity including design components

to improve street lighting infrastructure projects to

increase safety of pedestrian street crossing and use of

traffic calming approaches such as speed humps amp

traffic circles are effective in increasing physical activity

--Both community-scale amp street-scale policies amp practices

are effective in increasing physical activity

Recommended Community Strategies Encourage Communities to Organize for Change

Participate in community coalitions or

partnerships to address obesity

--Little evidence is available to determine the

impact of community coalitions on obesity

prevention

--The presence of anti-smoking community

coalitions has been associated with lower rates

of tobacco consumption

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

$103 million awarded to 61 states and

communities including state amp local government

agencies tribes amp territories amp state amp local non-

profit organizations

To build capacity to implement changes for

community prevention efforts to ensure long-

term success

To implement evidence-based and practice-

based programs to improve health amp wellness

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Priority areas are

Tobacco-free living

Active living and healthy eating

Evidence-based quality clinical and other

preventive health services for prevention

and control of high blood pressure and

high cholesterol

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Applicants proposed specific activities in

line with their chosen priority areas in their

applications

Grantee activities will not be finalized until

plans are negotiated with CDC by early

2012

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Capacity-Building Award

The Confederated Tribes of The Chehalis

Reservation is receiving a $498663 planning

award to build capacity to support healthy

lifestyles among their tribal population of 1500

in Washington State

Work will target tobacco-free living active living

and healthy eating and quality clinical and other

healthy serviceswwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Implementation Award

Austin TX Dept of Health and Human Services

is receiving $1026158 to serve Travis County

(Austin) to expand efforts in tobacco-free living

active living and healthy eating quality clinical

and other preventive services social and

emotional wellness and healthy and safe

physical environmentswwwcdcgov1052011

Building sustainable healthy

communities Bottom line

Obesity is an environmental problem

Despite progress in genetic research public health advances only will occur when we take the environment seriously

Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment

Until we do this we will not make substantial progress in addressing the epidemic of obesity

Poston amp Foreyt Atherosclerosis 1999

Whatrsquos the best approach

Integrate all sectors of society into community

change interventions

Incorporate

Science amp Technology

Education

FamilyCommunity

Healthcare

Arts amp Entertainment

Law amp Politics

Commerce amp Trade

Sectors of Society

Arts amp Entertainm

ent

Commerce amp Trade

Education

FamilyCommunity

Healthcare

Law amp Politics

Science amp Technology

Project FIT rationale design and baseline characteristics of a school- and community-

based intervention to address physical activity and healthy eating among low-income

elementary school children

Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D

Oh HJ Orth J Randall S Mayfield K Holmes D

Source

Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu

Abstract

BACKGROUND

This paper describes Project FIT a collaboration between the public school system local

health systems physicians neighborhood associations businesses faith-based leaders

community agencies and university researchers to develop a multi-faceted approach to

promote physical activity and healthy eating toward the general goal of preventing and

reducing childhood obesity among children in Grand Rapids MI USA

METHODSDESIGN

There are four overall components to Project FIT school community social marketing and

school staff wellness - all that focus on 1) increasing access to safe and affordable physical

activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)

improving the affordability and availability of nutritious food in the neighborhoods surrounding

the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding

nutrition and physical activity among school staff parents and students 4) impacting the

culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging

dialogue among all community partners to leverage existing programs and introduce new

ones

1-Year Changes in Markers of

Blood Pressure ControlMarkers of Blood Pressure

Control ILI DSE P-value

Systolic BP (mmHg) BL

Systolic BP (mmHg) Y1

Y1 ndash Baseline

1282

1214

-68

1294

1266

-28

026

lt0001

lt0001

Diastolic BP (mmHg) BL

Diastolic BP (mmHg) Y1

Y1 ndash Baseline

699

670

-30

704

686

-18

011

lt0001

lt0001

Antihypertensive medications BL

Antihypertensive medications Y1

Y1 ndash Baseline

753

752

-01

737

759

22

023

054

002

1-Year Changes in Markers of Lipid

Control

Markers of Lipid Control ILI DSE P-value

LDL-cholesterol (mgdl) BL

LDL-cholesterol (mgdl) Y1

Y1 ndash Baseline

1122

1070

-52

1124

1067

-57

078

074

049

HDL-cholesterol (mgdl) BL

HDL-cholesterol (mgdl) Y1

Y1 ndash Baseline

435

469

34

436

449

14

080

lt0001

lt0001

Triglycerides (mgdl) BL

Triglycerides (mgdl) Y1

Y1 ndash Baseline

1828

1525

-303

1800

1654

-146

038

lt0001

lt0001

Lipid lowering medications BL

Lipid lowering medications Y1

Y1 ndash Baseline

494

530

37

484

578

94

052

lt0001

lt0001

1-Year Changes in Percent of Participants

Meeting ADA Goals

ADA Goal ILI DSE P-value

Hemoglobin A1c lt 7 BL

Hemoglobin A1c lt 7 Y1

Y1 ndash Baseline

463

727

264

454

508

54

050

lt0001

lt0001

Blood pressure lt 13080 mmHg BL

Blood pressure lt 13080 mmHg Y1

Y1 ndash Baseline

535

686

151

499

570

70

001

lt0001

lt0001

LDL-cholesterol lt 100 mgdl BL

LDL-cholesterol lt 100 mgdl Y1

Y1 ndash Baseline

371

438

67

369

449

80

087

045

034

All three goals BL

All three goals Y1

Y1 ndash Baseline

108

236

128

95

160

65

013

lt0001

lt0001

Mean Changes in Weight Fitness amp BP

Averaged Over Four Years

DSE

Mean

ILI

Mean

P-value

Weight Loss

( initial wt)

-088 -615 lt 00001

Fitness

( METS)

196 1274 lt00001

HbA1c -009 -036 lt 00001

SBP (mm Hg) -297 -533 lt 00001

DBP (mm Hg) -248 -292 0012

Look AHEAD Research Group Arch Int Med 2010

Mean Changes in Lipid Profile

Averaged Over Four Years

DSE

Mean

ILI

Mean

P-value

HDL (mgdl) 197 367 lt00001

TG (mgdl) -1975 -2556 00006

LDL (mgdl) -1284 -1127 0009

LDL (mgdl)

(Adjusting for

medication use)

-922 -875 042

Look AHEAD Research Group Arch Int Med 2010

Percent () Completing Outcome

Measures at Years 1-4

Intervention Group

(ILI)

Year 1 971

Year 2 949

Year 3 940

Year 4 941

Comparison Group

(DSE)

Year 1 957

Year 2 935

Year 3 938

Year 4 931

Look AHEAD Summary

ILI had significantly greater improvements than DSE in all CVD risk factors averaged across 4 years (except LDL-C)

There may be long-term beneficial effects from this 4-year period in which ILI subjects have been exposed to lower CVD risk factors

Longer follow-ups will determine whether these lowered CVD risk factors can be maintained amp whether lifestyle intervention has positive effects on CVD morbidity amp mortality

Mary J

Female

White

56 years old at start of Look AHEAD

study

Past Medical History Type 2 diabetes

overweight diverticulosis arthritis

sleep apnea back pain

Mary J

bullLong term strugglesbull Helping youngest daughter with

personal issues and children

bull Rotator cuff problems

bull Degenerative disks in back

bull Rheumatoid arthritis

bull Diabetes

bull Physically demanding job

bull Financial struggles

Pounds

Years

82007 grandkids enter pre-school

Catherine L

Female

White

47 years old at start of Look AHEAD

study

Past Medical History Type 2 diabetes

overweight high blood pressure

hypothyroidism back pain

Catherine L

Long term struggles

bull Motherrsquos declining health and death

bull Multiple serious injuries

bull Sudden death of sister

bull Death of step-father

bull Declining economy

bull Children living at home

Pounds

Years

Realistic Management Goals

5-10 weight loss

Health energy and fitness

Well-being and self-esteem

Mood and appearance

Functional and recreational

activity

Key Elements

Focus on health and energy

Food and physical activity diaries

Gradual increase in physical activity

Gradual reduction in dietary fat

No feelings of food deprivation

Social support groups

Recommended Strategies for Building

Sustainable Healthy Communities

Overview from USA

Promote the availability of affordable healthy

food and beverages

Support healthy food and beverage choices

Encourage breastfeeding

Encourage physical activity or limit sedentary

activity among children amp youth

Create safe communities that support physical

activity

Encourage communities to organize for change

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Increase the availability of healthier food and

beverage choices in public service venues (eg

schools city amp county buildings etc)

--Insufficient evidence in school-based programs

--Associations suggest availability amp increased

consumption

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve availability of affordable healthier

food amp beverage choices in public service

venues

--Reducing the cost of healthier foods

increases their purchase

--Providing coupons redeemable for

healthier foods increases their purchase

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve geographic availability of

supermarkets in underserved areas

-- Greater access to nearby supermarkets is

associated with healthier eating behaviors

-- Increasing the number of supermarkets in

underserved neighborhoods increased

real estate values increased economic

activity amp employment amp resulted in lower

food prices

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Provide incentives to food retailers to locate in

andor offer healthier food choices in

underserved areas

-- Presence of retail venues that provide healthier

foods is associated with better nutrition

-- Greater availability of supermarkets was

associated with lower adolescent BMI scores

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Improve availability of mechanisms for

purchasing foods from farms

--Evidence supporting a direct link between

purchasing food from farms amp improved diet is

limited

--Two studies of initiatives to encourage

participation in farmersrsquo market showed

increased intention to eat more fruits amp

vegetables but no direct evidence

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Provide incentives for the production

distribution and procurement of foods from local

farms

--No evidence has been published to link local

food production amp health outcomes

--There is a current study exploring the potential

nutritional amp health benefits of eating locally

grown foods

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Restrict availability of less healthy foods amp

beverages in public service venues

--No peer-reviewed studies examined the impact

designed to restrict availability of less healthy

foods in public service venues

--21 states have policies that restrict the sale of

competitive foods in schools beyond USDA

regulations however no studies have evaluated

the impact of the policies

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Institute smaller portion size options in public

service venues

--Evidence is lacking to demonstrate effectiveness

of population-based interventions aimed at

reducing portion sizes in public service venues

--Evidence from clinical studies in laboratories

demonstrates decreasing portion sizes

decreases energy intake

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Limit advertisements of less healthy foods amp

beverages

--Little evidence is available regarding the impact

of restricting advertising on purchasing amp

consumption of less healthy foods

--Cross-sectional time-series studies of tobacco-

control efforts suggest an association between

advertising bans amp decreased tobacco

consumption

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Discourage consumption of sugar-sweetened

beverages

--One longitudinal study of a school-based

intervention among Native-American high school

students showed a substantial reduction in

sugar-sweetened beverages over a 3-year

period

--A RCT of a home-based intervention that

eliminated sugar-sweetened beverages showed

reduction in BMI scores

Recommended Community Strategies Strategies to encourage breastfeeding

Increase support for breastfeeding

--Evidence directly linking environmental

interventions that support breastfeeding with

obesity-related outcomes is lacking

--Epidemiologic studies indicate that breastfeeding

helps prevent pediatric obesity

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Require physical education in schools

--14 studies have demonstrated that school-based

PE was effective in increasing levels of physical

activity and improving physical fitness

--Minimum of 150 minwk in elementary schools

225 minwk in middle schools and high schools

throughout the school year as recommended by

NASPE

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Increase opportunities for extracurricular

physical activity

--Participation in after-school programs increased

studentsrsquo level of physical activity amp improved

obesity-related outcomes (improved CV fitness

reduced body fat)

--2 pilot studies providing extracurricular physical

activity showed increased levels of PA amp

decreased sedentary behavior

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Reduce screen time in public service venues

--A school-based RCT indicated that children who

reduced their television videotape amp video

game use had significant decrease in BMI tricep

skin fold thickness amp waist circumference

compared to controls

--Spending less time watching television is

associated with increased physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Improve access to outdoor recreational

facilities

--Review of 108 studies indicated that access to facilities

and programs for recreation near their homes amp time

spent outdoors correlated positively with increased

physical activity among childrenamp adults

--Perceptions that footpaths are safe for walking was

significantly associated with adults being classified as

physically active at a level sufficient for health benefits

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting

bicycling

--Longitudinal intervention studies have

demonstrated that improving bicycling

infrastructure is associated with increased

frequency of bicycling

--Cross-sectional studies indicated a significant

association between bicycling infrastructure amp

frequency of biking

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting walking

--Reviews of cross-sectional studies of

environmental correlates of physical activity amp

walking generally find a positive association

between infrastructure supportive of walking amp

physical activity

--Identifying amp creating safe routes to school

together with educational components

increased the number of students walking to

school

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Locating schools within easy walking

distance of residential areas

--Community-scale urban design amp land use policies amp

practices including locating schools stores workplaces

amp recreation areas close to residential areas are

effective in facilitating an increase in levels of physical

activity

--Majority of efforts to encourage walking to school involve

improving the routes rather than improving the location

of schools

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Improve access to public transportation

--Insufficient evidence exists to determine

effectiveness of transportation policies in

increasing the level of physical activity or

improving fitness

--1 study indicated that 29 of individuals who

walk to and from public transit achieve at least

30 minutes of daily physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Zone for mixed-use development

--Allows residential commercial institutional amp

other public land uses to be located in close

proximity to one another

--Studies using correlation analyses amp regression

models indicated that mixed land use was

associated with increased walking amp cycling

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance personal safety in areas where

persons are or could be physically active

--Cross-sectional studies have demonstrated a

negative relationship between crime rates andor

perceived safety amp physical activity in

neighborhoods

--Few intervention studies have evaluated the

impact of policies amp practices to improve

personal safety on physical activity

Geospatial Mapping Linking Urban

Environments to Health Risk

Measure association between environmental variables amp health risk factors

Assess relationships between variables at different levels of analysis

Used in conjunction with linear analyses

Our Community Environmental Model

of Obesity

Community Factors

Poverty

Crime

Grocery Quality

Restaurants

Parks

Sidewalks

Fast Food Outlets

Recreational

Facilities

Individual Factors

Dietary Intake

Physical Activity

Genetics

Family History

StressCoping

Eating Disorders

Psychological

Problems

Weight

Status

Chosen Neighborhoods

Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped

We then matched census-block groups within the income groups by population density and percentage of minority representation

One matched block group per income level was randomly selected

Prevalence of Obesity in

Block-Groups

0

5

10

15

20

25

30

35

40

45

50

Ag

e-a

dju

sted

Ob

esit

y P

rev

ale

nce

(

)

High-Income Low-Income

Age-standardized to the 1990 US Census

Density of Environmental Factors in the

Community Contributes to a ldquoToxicrdquo

Obesity Environment

0

2

4

6

8

10

12

14

16

18

Fast-food Convenience Store Bars

Den

sity

10

00

perso

ns

High-Income Low-Income

COMMUNITYrsquoS PERCEPTION OF SAFETY

0

5

10

15

20

25

30

35

40

Daytime Nighttime

Perc

en

t (

) F

eeli

ng

So

mew

hat

Safe

or

Un

safe

Low-Income High-Income

Percent Substandard (or worse) Housing

or Ground Conditions

of Residential Properties

0

10

20

30

Structural Grounds

Perc

en

t (

)

Low-Income High-Income

CONCLUSIONS

These data suggest that the higher

frequency of outlets providing

calorically-dense foods and alcohol may

contribute to greater obesity prevalence

in residents of low-income communities

More research is needed to thoroughly

document environmental determinants

of health and obesity

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

From 1994-1998 HUD randomly assigned

4498 women with children living in public

housing in high-poverty urban census

tracts to one of three groups (1) housing

vouchers redeemable only if they moved

to a low-poverty census tract (2)

unrestricted vouchers or (3) control group

(no vouchers)

Ludwig et al NEJM 201136516

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

10-12 year follow-up showed modest but

potentially important reductions in the

prevalence of extreme obesity amp diabetes in the

group moving from a neighborhood with high

poverty on one of low poverty compared to the

control group

No differences between the group receiving

traditional vouchers amp the control group

ldquoNeighborhoods matterrdquo

Ludwig et al NEJM 201136516

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance traffic safety in areas where

persons are or could be physically active

--Community-scale urban design amp land use policies to

promote physical activity including design components

to improve street lighting infrastructure projects to

increase safety of pedestrian street crossing and use of

traffic calming approaches such as speed humps amp

traffic circles are effective in increasing physical activity

--Both community-scale amp street-scale policies amp practices

are effective in increasing physical activity

Recommended Community Strategies Encourage Communities to Organize for Change

Participate in community coalitions or

partnerships to address obesity

--Little evidence is available to determine the

impact of community coalitions on obesity

prevention

--The presence of anti-smoking community

coalitions has been associated with lower rates

of tobacco consumption

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

$103 million awarded to 61 states and

communities including state amp local government

agencies tribes amp territories amp state amp local non-

profit organizations

To build capacity to implement changes for

community prevention efforts to ensure long-

term success

To implement evidence-based and practice-

based programs to improve health amp wellness

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Priority areas are

Tobacco-free living

Active living and healthy eating

Evidence-based quality clinical and other

preventive health services for prevention

and control of high blood pressure and

high cholesterol

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Applicants proposed specific activities in

line with their chosen priority areas in their

applications

Grantee activities will not be finalized until

plans are negotiated with CDC by early

2012

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Capacity-Building Award

The Confederated Tribes of The Chehalis

Reservation is receiving a $498663 planning

award to build capacity to support healthy

lifestyles among their tribal population of 1500

in Washington State

Work will target tobacco-free living active living

and healthy eating and quality clinical and other

healthy serviceswwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Implementation Award

Austin TX Dept of Health and Human Services

is receiving $1026158 to serve Travis County

(Austin) to expand efforts in tobacco-free living

active living and healthy eating quality clinical

and other preventive services social and

emotional wellness and healthy and safe

physical environmentswwwcdcgov1052011

Building sustainable healthy

communities Bottom line

Obesity is an environmental problem

Despite progress in genetic research public health advances only will occur when we take the environment seriously

Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment

Until we do this we will not make substantial progress in addressing the epidemic of obesity

Poston amp Foreyt Atherosclerosis 1999

Whatrsquos the best approach

Integrate all sectors of society into community

change interventions

Incorporate

Science amp Technology

Education

FamilyCommunity

Healthcare

Arts amp Entertainment

Law amp Politics

Commerce amp Trade

Sectors of Society

Arts amp Entertainm

ent

Commerce amp Trade

Education

FamilyCommunity

Healthcare

Law amp Politics

Science amp Technology

Project FIT rationale design and baseline characteristics of a school- and community-

based intervention to address physical activity and healthy eating among low-income

elementary school children

Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D

Oh HJ Orth J Randall S Mayfield K Holmes D

Source

Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu

Abstract

BACKGROUND

This paper describes Project FIT a collaboration between the public school system local

health systems physicians neighborhood associations businesses faith-based leaders

community agencies and university researchers to develop a multi-faceted approach to

promote physical activity and healthy eating toward the general goal of preventing and

reducing childhood obesity among children in Grand Rapids MI USA

METHODSDESIGN

There are four overall components to Project FIT school community social marketing and

school staff wellness - all that focus on 1) increasing access to safe and affordable physical

activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)

improving the affordability and availability of nutritious food in the neighborhoods surrounding

the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding

nutrition and physical activity among school staff parents and students 4) impacting the

culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging

dialogue among all community partners to leverage existing programs and introduce new

ones

1-Year Changes in Markers of Lipid

Control

Markers of Lipid Control ILI DSE P-value

LDL-cholesterol (mgdl) BL

LDL-cholesterol (mgdl) Y1

Y1 ndash Baseline

1122

1070

-52

1124

1067

-57

078

074

049

HDL-cholesterol (mgdl) BL

HDL-cholesterol (mgdl) Y1

Y1 ndash Baseline

435

469

34

436

449

14

080

lt0001

lt0001

Triglycerides (mgdl) BL

Triglycerides (mgdl) Y1

Y1 ndash Baseline

1828

1525

-303

1800

1654

-146

038

lt0001

lt0001

Lipid lowering medications BL

Lipid lowering medications Y1

Y1 ndash Baseline

494

530

37

484

578

94

052

lt0001

lt0001

1-Year Changes in Percent of Participants

Meeting ADA Goals

ADA Goal ILI DSE P-value

Hemoglobin A1c lt 7 BL

Hemoglobin A1c lt 7 Y1

Y1 ndash Baseline

463

727

264

454

508

54

050

lt0001

lt0001

Blood pressure lt 13080 mmHg BL

Blood pressure lt 13080 mmHg Y1

Y1 ndash Baseline

535

686

151

499

570

70

001

lt0001

lt0001

LDL-cholesterol lt 100 mgdl BL

LDL-cholesterol lt 100 mgdl Y1

Y1 ndash Baseline

371

438

67

369

449

80

087

045

034

All three goals BL

All three goals Y1

Y1 ndash Baseline

108

236

128

95

160

65

013

lt0001

lt0001

Mean Changes in Weight Fitness amp BP

Averaged Over Four Years

DSE

Mean

ILI

Mean

P-value

Weight Loss

( initial wt)

-088 -615 lt 00001

Fitness

( METS)

196 1274 lt00001

HbA1c -009 -036 lt 00001

SBP (mm Hg) -297 -533 lt 00001

DBP (mm Hg) -248 -292 0012

Look AHEAD Research Group Arch Int Med 2010

Mean Changes in Lipid Profile

Averaged Over Four Years

DSE

Mean

ILI

Mean

P-value

HDL (mgdl) 197 367 lt00001

TG (mgdl) -1975 -2556 00006

LDL (mgdl) -1284 -1127 0009

LDL (mgdl)

(Adjusting for

medication use)

-922 -875 042

Look AHEAD Research Group Arch Int Med 2010

Percent () Completing Outcome

Measures at Years 1-4

Intervention Group

(ILI)

Year 1 971

Year 2 949

Year 3 940

Year 4 941

Comparison Group

(DSE)

Year 1 957

Year 2 935

Year 3 938

Year 4 931

Look AHEAD Summary

ILI had significantly greater improvements than DSE in all CVD risk factors averaged across 4 years (except LDL-C)

There may be long-term beneficial effects from this 4-year period in which ILI subjects have been exposed to lower CVD risk factors

Longer follow-ups will determine whether these lowered CVD risk factors can be maintained amp whether lifestyle intervention has positive effects on CVD morbidity amp mortality

Mary J

Female

White

56 years old at start of Look AHEAD

study

Past Medical History Type 2 diabetes

overweight diverticulosis arthritis

sleep apnea back pain

Mary J

bullLong term strugglesbull Helping youngest daughter with

personal issues and children

bull Rotator cuff problems

bull Degenerative disks in back

bull Rheumatoid arthritis

bull Diabetes

bull Physically demanding job

bull Financial struggles

Pounds

Years

82007 grandkids enter pre-school

Catherine L

Female

White

47 years old at start of Look AHEAD

study

Past Medical History Type 2 diabetes

overweight high blood pressure

hypothyroidism back pain

Catherine L

Long term struggles

bull Motherrsquos declining health and death

bull Multiple serious injuries

bull Sudden death of sister

bull Death of step-father

bull Declining economy

bull Children living at home

Pounds

Years

Realistic Management Goals

5-10 weight loss

Health energy and fitness

Well-being and self-esteem

Mood and appearance

Functional and recreational

activity

Key Elements

Focus on health and energy

Food and physical activity diaries

Gradual increase in physical activity

Gradual reduction in dietary fat

No feelings of food deprivation

Social support groups

Recommended Strategies for Building

Sustainable Healthy Communities

Overview from USA

Promote the availability of affordable healthy

food and beverages

Support healthy food and beverage choices

Encourage breastfeeding

Encourage physical activity or limit sedentary

activity among children amp youth

Create safe communities that support physical

activity

Encourage communities to organize for change

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Increase the availability of healthier food and

beverage choices in public service venues (eg

schools city amp county buildings etc)

--Insufficient evidence in school-based programs

--Associations suggest availability amp increased

consumption

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve availability of affordable healthier

food amp beverage choices in public service

venues

--Reducing the cost of healthier foods

increases their purchase

--Providing coupons redeemable for

healthier foods increases their purchase

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve geographic availability of

supermarkets in underserved areas

-- Greater access to nearby supermarkets is

associated with healthier eating behaviors

-- Increasing the number of supermarkets in

underserved neighborhoods increased

real estate values increased economic

activity amp employment amp resulted in lower

food prices

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Provide incentives to food retailers to locate in

andor offer healthier food choices in

underserved areas

-- Presence of retail venues that provide healthier

foods is associated with better nutrition

-- Greater availability of supermarkets was

associated with lower adolescent BMI scores

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Improve availability of mechanisms for

purchasing foods from farms

--Evidence supporting a direct link between

purchasing food from farms amp improved diet is

limited

--Two studies of initiatives to encourage

participation in farmersrsquo market showed

increased intention to eat more fruits amp

vegetables but no direct evidence

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Provide incentives for the production

distribution and procurement of foods from local

farms

--No evidence has been published to link local

food production amp health outcomes

--There is a current study exploring the potential

nutritional amp health benefits of eating locally

grown foods

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Restrict availability of less healthy foods amp

beverages in public service venues

--No peer-reviewed studies examined the impact

designed to restrict availability of less healthy

foods in public service venues

--21 states have policies that restrict the sale of

competitive foods in schools beyond USDA

regulations however no studies have evaluated

the impact of the policies

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Institute smaller portion size options in public

service venues

--Evidence is lacking to demonstrate effectiveness

of population-based interventions aimed at

reducing portion sizes in public service venues

--Evidence from clinical studies in laboratories

demonstrates decreasing portion sizes

decreases energy intake

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Limit advertisements of less healthy foods amp

beverages

--Little evidence is available regarding the impact

of restricting advertising on purchasing amp

consumption of less healthy foods

--Cross-sectional time-series studies of tobacco-

control efforts suggest an association between

advertising bans amp decreased tobacco

consumption

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Discourage consumption of sugar-sweetened

beverages

--One longitudinal study of a school-based

intervention among Native-American high school

students showed a substantial reduction in

sugar-sweetened beverages over a 3-year

period

--A RCT of a home-based intervention that

eliminated sugar-sweetened beverages showed

reduction in BMI scores

Recommended Community Strategies Strategies to encourage breastfeeding

Increase support for breastfeeding

--Evidence directly linking environmental

interventions that support breastfeeding with

obesity-related outcomes is lacking

--Epidemiologic studies indicate that breastfeeding

helps prevent pediatric obesity

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Require physical education in schools

--14 studies have demonstrated that school-based

PE was effective in increasing levels of physical

activity and improving physical fitness

--Minimum of 150 minwk in elementary schools

225 minwk in middle schools and high schools

throughout the school year as recommended by

NASPE

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Increase opportunities for extracurricular

physical activity

--Participation in after-school programs increased

studentsrsquo level of physical activity amp improved

obesity-related outcomes (improved CV fitness

reduced body fat)

--2 pilot studies providing extracurricular physical

activity showed increased levels of PA amp

decreased sedentary behavior

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Reduce screen time in public service venues

--A school-based RCT indicated that children who

reduced their television videotape amp video

game use had significant decrease in BMI tricep

skin fold thickness amp waist circumference

compared to controls

--Spending less time watching television is

associated with increased physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Improve access to outdoor recreational

facilities

--Review of 108 studies indicated that access to facilities

and programs for recreation near their homes amp time

spent outdoors correlated positively with increased

physical activity among childrenamp adults

--Perceptions that footpaths are safe for walking was

significantly associated with adults being classified as

physically active at a level sufficient for health benefits

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting

bicycling

--Longitudinal intervention studies have

demonstrated that improving bicycling

infrastructure is associated with increased

frequency of bicycling

--Cross-sectional studies indicated a significant

association between bicycling infrastructure amp

frequency of biking

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting walking

--Reviews of cross-sectional studies of

environmental correlates of physical activity amp

walking generally find a positive association

between infrastructure supportive of walking amp

physical activity

--Identifying amp creating safe routes to school

together with educational components

increased the number of students walking to

school

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Locating schools within easy walking

distance of residential areas

--Community-scale urban design amp land use policies amp

practices including locating schools stores workplaces

amp recreation areas close to residential areas are

effective in facilitating an increase in levels of physical

activity

--Majority of efforts to encourage walking to school involve

improving the routes rather than improving the location

of schools

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Improve access to public transportation

--Insufficient evidence exists to determine

effectiveness of transportation policies in

increasing the level of physical activity or

improving fitness

--1 study indicated that 29 of individuals who

walk to and from public transit achieve at least

30 minutes of daily physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Zone for mixed-use development

--Allows residential commercial institutional amp

other public land uses to be located in close

proximity to one another

--Studies using correlation analyses amp regression

models indicated that mixed land use was

associated with increased walking amp cycling

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance personal safety in areas where

persons are or could be physically active

--Cross-sectional studies have demonstrated a

negative relationship between crime rates andor

perceived safety amp physical activity in

neighborhoods

--Few intervention studies have evaluated the

impact of policies amp practices to improve

personal safety on physical activity

Geospatial Mapping Linking Urban

Environments to Health Risk

Measure association between environmental variables amp health risk factors

Assess relationships between variables at different levels of analysis

Used in conjunction with linear analyses

Our Community Environmental Model

of Obesity

Community Factors

Poverty

Crime

Grocery Quality

Restaurants

Parks

Sidewalks

Fast Food Outlets

Recreational

Facilities

Individual Factors

Dietary Intake

Physical Activity

Genetics

Family History

StressCoping

Eating Disorders

Psychological

Problems

Weight

Status

Chosen Neighborhoods

Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped

We then matched census-block groups within the income groups by population density and percentage of minority representation

One matched block group per income level was randomly selected

Prevalence of Obesity in

Block-Groups

0

5

10

15

20

25

30

35

40

45

50

Ag

e-a

dju

sted

Ob

esit

y P

rev

ale

nce

(

)

High-Income Low-Income

Age-standardized to the 1990 US Census

Density of Environmental Factors in the

Community Contributes to a ldquoToxicrdquo

Obesity Environment

0

2

4

6

8

10

12

14

16

18

Fast-food Convenience Store Bars

Den

sity

10

00

perso

ns

High-Income Low-Income

COMMUNITYrsquoS PERCEPTION OF SAFETY

0

5

10

15

20

25

30

35

40

Daytime Nighttime

Perc

en

t (

) F

eeli

ng

So

mew

hat

Safe

or

Un

safe

Low-Income High-Income

Percent Substandard (or worse) Housing

or Ground Conditions

of Residential Properties

0

10

20

30

Structural Grounds

Perc

en

t (

)

Low-Income High-Income

CONCLUSIONS

These data suggest that the higher

frequency of outlets providing

calorically-dense foods and alcohol may

contribute to greater obesity prevalence

in residents of low-income communities

More research is needed to thoroughly

document environmental determinants

of health and obesity

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

From 1994-1998 HUD randomly assigned

4498 women with children living in public

housing in high-poverty urban census

tracts to one of three groups (1) housing

vouchers redeemable only if they moved

to a low-poverty census tract (2)

unrestricted vouchers or (3) control group

(no vouchers)

Ludwig et al NEJM 201136516

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

10-12 year follow-up showed modest but

potentially important reductions in the

prevalence of extreme obesity amp diabetes in the

group moving from a neighborhood with high

poverty on one of low poverty compared to the

control group

No differences between the group receiving

traditional vouchers amp the control group

ldquoNeighborhoods matterrdquo

Ludwig et al NEJM 201136516

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance traffic safety in areas where

persons are or could be physically active

--Community-scale urban design amp land use policies to

promote physical activity including design components

to improve street lighting infrastructure projects to

increase safety of pedestrian street crossing and use of

traffic calming approaches such as speed humps amp

traffic circles are effective in increasing physical activity

--Both community-scale amp street-scale policies amp practices

are effective in increasing physical activity

Recommended Community Strategies Encourage Communities to Organize for Change

Participate in community coalitions or

partnerships to address obesity

--Little evidence is available to determine the

impact of community coalitions on obesity

prevention

--The presence of anti-smoking community

coalitions has been associated with lower rates

of tobacco consumption

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

$103 million awarded to 61 states and

communities including state amp local government

agencies tribes amp territories amp state amp local non-

profit organizations

To build capacity to implement changes for

community prevention efforts to ensure long-

term success

To implement evidence-based and practice-

based programs to improve health amp wellness

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Priority areas are

Tobacco-free living

Active living and healthy eating

Evidence-based quality clinical and other

preventive health services for prevention

and control of high blood pressure and

high cholesterol

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Applicants proposed specific activities in

line with their chosen priority areas in their

applications

Grantee activities will not be finalized until

plans are negotiated with CDC by early

2012

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Capacity-Building Award

The Confederated Tribes of The Chehalis

Reservation is receiving a $498663 planning

award to build capacity to support healthy

lifestyles among their tribal population of 1500

in Washington State

Work will target tobacco-free living active living

and healthy eating and quality clinical and other

healthy serviceswwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Implementation Award

Austin TX Dept of Health and Human Services

is receiving $1026158 to serve Travis County

(Austin) to expand efforts in tobacco-free living

active living and healthy eating quality clinical

and other preventive services social and

emotional wellness and healthy and safe

physical environmentswwwcdcgov1052011

Building sustainable healthy

communities Bottom line

Obesity is an environmental problem

Despite progress in genetic research public health advances only will occur when we take the environment seriously

Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment

Until we do this we will not make substantial progress in addressing the epidemic of obesity

Poston amp Foreyt Atherosclerosis 1999

Whatrsquos the best approach

Integrate all sectors of society into community

change interventions

Incorporate

Science amp Technology

Education

FamilyCommunity

Healthcare

Arts amp Entertainment

Law amp Politics

Commerce amp Trade

Sectors of Society

Arts amp Entertainm

ent

Commerce amp Trade

Education

FamilyCommunity

Healthcare

Law amp Politics

Science amp Technology

Project FIT rationale design and baseline characteristics of a school- and community-

based intervention to address physical activity and healthy eating among low-income

elementary school children

Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D

Oh HJ Orth J Randall S Mayfield K Holmes D

Source

Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu

Abstract

BACKGROUND

This paper describes Project FIT a collaboration between the public school system local

health systems physicians neighborhood associations businesses faith-based leaders

community agencies and university researchers to develop a multi-faceted approach to

promote physical activity and healthy eating toward the general goal of preventing and

reducing childhood obesity among children in Grand Rapids MI USA

METHODSDESIGN

There are four overall components to Project FIT school community social marketing and

school staff wellness - all that focus on 1) increasing access to safe and affordable physical

activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)

improving the affordability and availability of nutritious food in the neighborhoods surrounding

the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding

nutrition and physical activity among school staff parents and students 4) impacting the

culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging

dialogue among all community partners to leverage existing programs and introduce new

ones

1-Year Changes in Percent of Participants

Meeting ADA Goals

ADA Goal ILI DSE P-value

Hemoglobin A1c lt 7 BL

Hemoglobin A1c lt 7 Y1

Y1 ndash Baseline

463

727

264

454

508

54

050

lt0001

lt0001

Blood pressure lt 13080 mmHg BL

Blood pressure lt 13080 mmHg Y1

Y1 ndash Baseline

535

686

151

499

570

70

001

lt0001

lt0001

LDL-cholesterol lt 100 mgdl BL

LDL-cholesterol lt 100 mgdl Y1

Y1 ndash Baseline

371

438

67

369

449

80

087

045

034

All three goals BL

All three goals Y1

Y1 ndash Baseline

108

236

128

95

160

65

013

lt0001

lt0001

Mean Changes in Weight Fitness amp BP

Averaged Over Four Years

DSE

Mean

ILI

Mean

P-value

Weight Loss

( initial wt)

-088 -615 lt 00001

Fitness

( METS)

196 1274 lt00001

HbA1c -009 -036 lt 00001

SBP (mm Hg) -297 -533 lt 00001

DBP (mm Hg) -248 -292 0012

Look AHEAD Research Group Arch Int Med 2010

Mean Changes in Lipid Profile

Averaged Over Four Years

DSE

Mean

ILI

Mean

P-value

HDL (mgdl) 197 367 lt00001

TG (mgdl) -1975 -2556 00006

LDL (mgdl) -1284 -1127 0009

LDL (mgdl)

(Adjusting for

medication use)

-922 -875 042

Look AHEAD Research Group Arch Int Med 2010

Percent () Completing Outcome

Measures at Years 1-4

Intervention Group

(ILI)

Year 1 971

Year 2 949

Year 3 940

Year 4 941

Comparison Group

(DSE)

Year 1 957

Year 2 935

Year 3 938

Year 4 931

Look AHEAD Summary

ILI had significantly greater improvements than DSE in all CVD risk factors averaged across 4 years (except LDL-C)

There may be long-term beneficial effects from this 4-year period in which ILI subjects have been exposed to lower CVD risk factors

Longer follow-ups will determine whether these lowered CVD risk factors can be maintained amp whether lifestyle intervention has positive effects on CVD morbidity amp mortality

Mary J

Female

White

56 years old at start of Look AHEAD

study

Past Medical History Type 2 diabetes

overweight diverticulosis arthritis

sleep apnea back pain

Mary J

bullLong term strugglesbull Helping youngest daughter with

personal issues and children

bull Rotator cuff problems

bull Degenerative disks in back

bull Rheumatoid arthritis

bull Diabetes

bull Physically demanding job

bull Financial struggles

Pounds

Years

82007 grandkids enter pre-school

Catherine L

Female

White

47 years old at start of Look AHEAD

study

Past Medical History Type 2 diabetes

overweight high blood pressure

hypothyroidism back pain

Catherine L

Long term struggles

bull Motherrsquos declining health and death

bull Multiple serious injuries

bull Sudden death of sister

bull Death of step-father

bull Declining economy

bull Children living at home

Pounds

Years

Realistic Management Goals

5-10 weight loss

Health energy and fitness

Well-being and self-esteem

Mood and appearance

Functional and recreational

activity

Key Elements

Focus on health and energy

Food and physical activity diaries

Gradual increase in physical activity

Gradual reduction in dietary fat

No feelings of food deprivation

Social support groups

Recommended Strategies for Building

Sustainable Healthy Communities

Overview from USA

Promote the availability of affordable healthy

food and beverages

Support healthy food and beverage choices

Encourage breastfeeding

Encourage physical activity or limit sedentary

activity among children amp youth

Create safe communities that support physical

activity

Encourage communities to organize for change

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Increase the availability of healthier food and

beverage choices in public service venues (eg

schools city amp county buildings etc)

--Insufficient evidence in school-based programs

--Associations suggest availability amp increased

consumption

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve availability of affordable healthier

food amp beverage choices in public service

venues

--Reducing the cost of healthier foods

increases their purchase

--Providing coupons redeemable for

healthier foods increases their purchase

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve geographic availability of

supermarkets in underserved areas

-- Greater access to nearby supermarkets is

associated with healthier eating behaviors

-- Increasing the number of supermarkets in

underserved neighborhoods increased

real estate values increased economic

activity amp employment amp resulted in lower

food prices

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Provide incentives to food retailers to locate in

andor offer healthier food choices in

underserved areas

-- Presence of retail venues that provide healthier

foods is associated with better nutrition

-- Greater availability of supermarkets was

associated with lower adolescent BMI scores

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Improve availability of mechanisms for

purchasing foods from farms

--Evidence supporting a direct link between

purchasing food from farms amp improved diet is

limited

--Two studies of initiatives to encourage

participation in farmersrsquo market showed

increased intention to eat more fruits amp

vegetables but no direct evidence

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Provide incentives for the production

distribution and procurement of foods from local

farms

--No evidence has been published to link local

food production amp health outcomes

--There is a current study exploring the potential

nutritional amp health benefits of eating locally

grown foods

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Restrict availability of less healthy foods amp

beverages in public service venues

--No peer-reviewed studies examined the impact

designed to restrict availability of less healthy

foods in public service venues

--21 states have policies that restrict the sale of

competitive foods in schools beyond USDA

regulations however no studies have evaluated

the impact of the policies

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Institute smaller portion size options in public

service venues

--Evidence is lacking to demonstrate effectiveness

of population-based interventions aimed at

reducing portion sizes in public service venues

--Evidence from clinical studies in laboratories

demonstrates decreasing portion sizes

decreases energy intake

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Limit advertisements of less healthy foods amp

beverages

--Little evidence is available regarding the impact

of restricting advertising on purchasing amp

consumption of less healthy foods

--Cross-sectional time-series studies of tobacco-

control efforts suggest an association between

advertising bans amp decreased tobacco

consumption

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Discourage consumption of sugar-sweetened

beverages

--One longitudinal study of a school-based

intervention among Native-American high school

students showed a substantial reduction in

sugar-sweetened beverages over a 3-year

period

--A RCT of a home-based intervention that

eliminated sugar-sweetened beverages showed

reduction in BMI scores

Recommended Community Strategies Strategies to encourage breastfeeding

Increase support for breastfeeding

--Evidence directly linking environmental

interventions that support breastfeeding with

obesity-related outcomes is lacking

--Epidemiologic studies indicate that breastfeeding

helps prevent pediatric obesity

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Require physical education in schools

--14 studies have demonstrated that school-based

PE was effective in increasing levels of physical

activity and improving physical fitness

--Minimum of 150 minwk in elementary schools

225 minwk in middle schools and high schools

throughout the school year as recommended by

NASPE

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Increase opportunities for extracurricular

physical activity

--Participation in after-school programs increased

studentsrsquo level of physical activity amp improved

obesity-related outcomes (improved CV fitness

reduced body fat)

--2 pilot studies providing extracurricular physical

activity showed increased levels of PA amp

decreased sedentary behavior

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Reduce screen time in public service venues

--A school-based RCT indicated that children who

reduced their television videotape amp video

game use had significant decrease in BMI tricep

skin fold thickness amp waist circumference

compared to controls

--Spending less time watching television is

associated with increased physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Improve access to outdoor recreational

facilities

--Review of 108 studies indicated that access to facilities

and programs for recreation near their homes amp time

spent outdoors correlated positively with increased

physical activity among childrenamp adults

--Perceptions that footpaths are safe for walking was

significantly associated with adults being classified as

physically active at a level sufficient for health benefits

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting

bicycling

--Longitudinal intervention studies have

demonstrated that improving bicycling

infrastructure is associated with increased

frequency of bicycling

--Cross-sectional studies indicated a significant

association between bicycling infrastructure amp

frequency of biking

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting walking

--Reviews of cross-sectional studies of

environmental correlates of physical activity amp

walking generally find a positive association

between infrastructure supportive of walking amp

physical activity

--Identifying amp creating safe routes to school

together with educational components

increased the number of students walking to

school

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Locating schools within easy walking

distance of residential areas

--Community-scale urban design amp land use policies amp

practices including locating schools stores workplaces

amp recreation areas close to residential areas are

effective in facilitating an increase in levels of physical

activity

--Majority of efforts to encourage walking to school involve

improving the routes rather than improving the location

of schools

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Improve access to public transportation

--Insufficient evidence exists to determine

effectiveness of transportation policies in

increasing the level of physical activity or

improving fitness

--1 study indicated that 29 of individuals who

walk to and from public transit achieve at least

30 minutes of daily physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Zone for mixed-use development

--Allows residential commercial institutional amp

other public land uses to be located in close

proximity to one another

--Studies using correlation analyses amp regression

models indicated that mixed land use was

associated with increased walking amp cycling

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance personal safety in areas where

persons are or could be physically active

--Cross-sectional studies have demonstrated a

negative relationship between crime rates andor

perceived safety amp physical activity in

neighborhoods

--Few intervention studies have evaluated the

impact of policies amp practices to improve

personal safety on physical activity

Geospatial Mapping Linking Urban

Environments to Health Risk

Measure association between environmental variables amp health risk factors

Assess relationships between variables at different levels of analysis

Used in conjunction with linear analyses

Our Community Environmental Model

of Obesity

Community Factors

Poverty

Crime

Grocery Quality

Restaurants

Parks

Sidewalks

Fast Food Outlets

Recreational

Facilities

Individual Factors

Dietary Intake

Physical Activity

Genetics

Family History

StressCoping

Eating Disorders

Psychological

Problems

Weight

Status

Chosen Neighborhoods

Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped

We then matched census-block groups within the income groups by population density and percentage of minority representation

One matched block group per income level was randomly selected

Prevalence of Obesity in

Block-Groups

0

5

10

15

20

25

30

35

40

45

50

Ag

e-a

dju

sted

Ob

esit

y P

rev

ale

nce

(

)

High-Income Low-Income

Age-standardized to the 1990 US Census

Density of Environmental Factors in the

Community Contributes to a ldquoToxicrdquo

Obesity Environment

0

2

4

6

8

10

12

14

16

18

Fast-food Convenience Store Bars

Den

sity

10

00

perso

ns

High-Income Low-Income

COMMUNITYrsquoS PERCEPTION OF SAFETY

0

5

10

15

20

25

30

35

40

Daytime Nighttime

Perc

en

t (

) F

eeli

ng

So

mew

hat

Safe

or

Un

safe

Low-Income High-Income

Percent Substandard (or worse) Housing

or Ground Conditions

of Residential Properties

0

10

20

30

Structural Grounds

Perc

en

t (

)

Low-Income High-Income

CONCLUSIONS

These data suggest that the higher

frequency of outlets providing

calorically-dense foods and alcohol may

contribute to greater obesity prevalence

in residents of low-income communities

More research is needed to thoroughly

document environmental determinants

of health and obesity

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

From 1994-1998 HUD randomly assigned

4498 women with children living in public

housing in high-poverty urban census

tracts to one of three groups (1) housing

vouchers redeemable only if they moved

to a low-poverty census tract (2)

unrestricted vouchers or (3) control group

(no vouchers)

Ludwig et al NEJM 201136516

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

10-12 year follow-up showed modest but

potentially important reductions in the

prevalence of extreme obesity amp diabetes in the

group moving from a neighborhood with high

poverty on one of low poverty compared to the

control group

No differences between the group receiving

traditional vouchers amp the control group

ldquoNeighborhoods matterrdquo

Ludwig et al NEJM 201136516

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance traffic safety in areas where

persons are or could be physically active

--Community-scale urban design amp land use policies to

promote physical activity including design components

to improve street lighting infrastructure projects to

increase safety of pedestrian street crossing and use of

traffic calming approaches such as speed humps amp

traffic circles are effective in increasing physical activity

--Both community-scale amp street-scale policies amp practices

are effective in increasing physical activity

Recommended Community Strategies Encourage Communities to Organize for Change

Participate in community coalitions or

partnerships to address obesity

--Little evidence is available to determine the

impact of community coalitions on obesity

prevention

--The presence of anti-smoking community

coalitions has been associated with lower rates

of tobacco consumption

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

$103 million awarded to 61 states and

communities including state amp local government

agencies tribes amp territories amp state amp local non-

profit organizations

To build capacity to implement changes for

community prevention efforts to ensure long-

term success

To implement evidence-based and practice-

based programs to improve health amp wellness

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Priority areas are

Tobacco-free living

Active living and healthy eating

Evidence-based quality clinical and other

preventive health services for prevention

and control of high blood pressure and

high cholesterol

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Applicants proposed specific activities in

line with their chosen priority areas in their

applications

Grantee activities will not be finalized until

plans are negotiated with CDC by early

2012

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Capacity-Building Award

The Confederated Tribes of The Chehalis

Reservation is receiving a $498663 planning

award to build capacity to support healthy

lifestyles among their tribal population of 1500

in Washington State

Work will target tobacco-free living active living

and healthy eating and quality clinical and other

healthy serviceswwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Implementation Award

Austin TX Dept of Health and Human Services

is receiving $1026158 to serve Travis County

(Austin) to expand efforts in tobacco-free living

active living and healthy eating quality clinical

and other preventive services social and

emotional wellness and healthy and safe

physical environmentswwwcdcgov1052011

Building sustainable healthy

communities Bottom line

Obesity is an environmental problem

Despite progress in genetic research public health advances only will occur when we take the environment seriously

Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment

Until we do this we will not make substantial progress in addressing the epidemic of obesity

Poston amp Foreyt Atherosclerosis 1999

Whatrsquos the best approach

Integrate all sectors of society into community

change interventions

Incorporate

Science amp Technology

Education

FamilyCommunity

Healthcare

Arts amp Entertainment

Law amp Politics

Commerce amp Trade

Sectors of Society

Arts amp Entertainm

ent

Commerce amp Trade

Education

FamilyCommunity

Healthcare

Law amp Politics

Science amp Technology

Project FIT rationale design and baseline characteristics of a school- and community-

based intervention to address physical activity and healthy eating among low-income

elementary school children

Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D

Oh HJ Orth J Randall S Mayfield K Holmes D

Source

Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu

Abstract

BACKGROUND

This paper describes Project FIT a collaboration between the public school system local

health systems physicians neighborhood associations businesses faith-based leaders

community agencies and university researchers to develop a multi-faceted approach to

promote physical activity and healthy eating toward the general goal of preventing and

reducing childhood obesity among children in Grand Rapids MI USA

METHODSDESIGN

There are four overall components to Project FIT school community social marketing and

school staff wellness - all that focus on 1) increasing access to safe and affordable physical

activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)

improving the affordability and availability of nutritious food in the neighborhoods surrounding

the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding

nutrition and physical activity among school staff parents and students 4) impacting the

culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging

dialogue among all community partners to leverage existing programs and introduce new

ones

Mean Changes in Weight Fitness amp BP

Averaged Over Four Years

DSE

Mean

ILI

Mean

P-value

Weight Loss

( initial wt)

-088 -615 lt 00001

Fitness

( METS)

196 1274 lt00001

HbA1c -009 -036 lt 00001

SBP (mm Hg) -297 -533 lt 00001

DBP (mm Hg) -248 -292 0012

Look AHEAD Research Group Arch Int Med 2010

Mean Changes in Lipid Profile

Averaged Over Four Years

DSE

Mean

ILI

Mean

P-value

HDL (mgdl) 197 367 lt00001

TG (mgdl) -1975 -2556 00006

LDL (mgdl) -1284 -1127 0009

LDL (mgdl)

(Adjusting for

medication use)

-922 -875 042

Look AHEAD Research Group Arch Int Med 2010

Percent () Completing Outcome

Measures at Years 1-4

Intervention Group

(ILI)

Year 1 971

Year 2 949

Year 3 940

Year 4 941

Comparison Group

(DSE)

Year 1 957

Year 2 935

Year 3 938

Year 4 931

Look AHEAD Summary

ILI had significantly greater improvements than DSE in all CVD risk factors averaged across 4 years (except LDL-C)

There may be long-term beneficial effects from this 4-year period in which ILI subjects have been exposed to lower CVD risk factors

Longer follow-ups will determine whether these lowered CVD risk factors can be maintained amp whether lifestyle intervention has positive effects on CVD morbidity amp mortality

Mary J

Female

White

56 years old at start of Look AHEAD

study

Past Medical History Type 2 diabetes

overweight diverticulosis arthritis

sleep apnea back pain

Mary J

bullLong term strugglesbull Helping youngest daughter with

personal issues and children

bull Rotator cuff problems

bull Degenerative disks in back

bull Rheumatoid arthritis

bull Diabetes

bull Physically demanding job

bull Financial struggles

Pounds

Years

82007 grandkids enter pre-school

Catherine L

Female

White

47 years old at start of Look AHEAD

study

Past Medical History Type 2 diabetes

overweight high blood pressure

hypothyroidism back pain

Catherine L

Long term struggles

bull Motherrsquos declining health and death

bull Multiple serious injuries

bull Sudden death of sister

bull Death of step-father

bull Declining economy

bull Children living at home

Pounds

Years

Realistic Management Goals

5-10 weight loss

Health energy and fitness

Well-being and self-esteem

Mood and appearance

Functional and recreational

activity

Key Elements

Focus on health and energy

Food and physical activity diaries

Gradual increase in physical activity

Gradual reduction in dietary fat

No feelings of food deprivation

Social support groups

Recommended Strategies for Building

Sustainable Healthy Communities

Overview from USA

Promote the availability of affordable healthy

food and beverages

Support healthy food and beverage choices

Encourage breastfeeding

Encourage physical activity or limit sedentary

activity among children amp youth

Create safe communities that support physical

activity

Encourage communities to organize for change

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Increase the availability of healthier food and

beverage choices in public service venues (eg

schools city amp county buildings etc)

--Insufficient evidence in school-based programs

--Associations suggest availability amp increased

consumption

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve availability of affordable healthier

food amp beverage choices in public service

venues

--Reducing the cost of healthier foods

increases their purchase

--Providing coupons redeemable for

healthier foods increases their purchase

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve geographic availability of

supermarkets in underserved areas

-- Greater access to nearby supermarkets is

associated with healthier eating behaviors

-- Increasing the number of supermarkets in

underserved neighborhoods increased

real estate values increased economic

activity amp employment amp resulted in lower

food prices

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Provide incentives to food retailers to locate in

andor offer healthier food choices in

underserved areas

-- Presence of retail venues that provide healthier

foods is associated with better nutrition

-- Greater availability of supermarkets was

associated with lower adolescent BMI scores

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Improve availability of mechanisms for

purchasing foods from farms

--Evidence supporting a direct link between

purchasing food from farms amp improved diet is

limited

--Two studies of initiatives to encourage

participation in farmersrsquo market showed

increased intention to eat more fruits amp

vegetables but no direct evidence

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Provide incentives for the production

distribution and procurement of foods from local

farms

--No evidence has been published to link local

food production amp health outcomes

--There is a current study exploring the potential

nutritional amp health benefits of eating locally

grown foods

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Restrict availability of less healthy foods amp

beverages in public service venues

--No peer-reviewed studies examined the impact

designed to restrict availability of less healthy

foods in public service venues

--21 states have policies that restrict the sale of

competitive foods in schools beyond USDA

regulations however no studies have evaluated

the impact of the policies

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Institute smaller portion size options in public

service venues

--Evidence is lacking to demonstrate effectiveness

of population-based interventions aimed at

reducing portion sizes in public service venues

--Evidence from clinical studies in laboratories

demonstrates decreasing portion sizes

decreases energy intake

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Limit advertisements of less healthy foods amp

beverages

--Little evidence is available regarding the impact

of restricting advertising on purchasing amp

consumption of less healthy foods

--Cross-sectional time-series studies of tobacco-

control efforts suggest an association between

advertising bans amp decreased tobacco

consumption

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Discourage consumption of sugar-sweetened

beverages

--One longitudinal study of a school-based

intervention among Native-American high school

students showed a substantial reduction in

sugar-sweetened beverages over a 3-year

period

--A RCT of a home-based intervention that

eliminated sugar-sweetened beverages showed

reduction in BMI scores

Recommended Community Strategies Strategies to encourage breastfeeding

Increase support for breastfeeding

--Evidence directly linking environmental

interventions that support breastfeeding with

obesity-related outcomes is lacking

--Epidemiologic studies indicate that breastfeeding

helps prevent pediatric obesity

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Require physical education in schools

--14 studies have demonstrated that school-based

PE was effective in increasing levels of physical

activity and improving physical fitness

--Minimum of 150 minwk in elementary schools

225 minwk in middle schools and high schools

throughout the school year as recommended by

NASPE

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Increase opportunities for extracurricular

physical activity

--Participation in after-school programs increased

studentsrsquo level of physical activity amp improved

obesity-related outcomes (improved CV fitness

reduced body fat)

--2 pilot studies providing extracurricular physical

activity showed increased levels of PA amp

decreased sedentary behavior

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Reduce screen time in public service venues

--A school-based RCT indicated that children who

reduced their television videotape amp video

game use had significant decrease in BMI tricep

skin fold thickness amp waist circumference

compared to controls

--Spending less time watching television is

associated with increased physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Improve access to outdoor recreational

facilities

--Review of 108 studies indicated that access to facilities

and programs for recreation near their homes amp time

spent outdoors correlated positively with increased

physical activity among childrenamp adults

--Perceptions that footpaths are safe for walking was

significantly associated with adults being classified as

physically active at a level sufficient for health benefits

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting

bicycling

--Longitudinal intervention studies have

demonstrated that improving bicycling

infrastructure is associated with increased

frequency of bicycling

--Cross-sectional studies indicated a significant

association between bicycling infrastructure amp

frequency of biking

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting walking

--Reviews of cross-sectional studies of

environmental correlates of physical activity amp

walking generally find a positive association

between infrastructure supportive of walking amp

physical activity

--Identifying amp creating safe routes to school

together with educational components

increased the number of students walking to

school

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Locating schools within easy walking

distance of residential areas

--Community-scale urban design amp land use policies amp

practices including locating schools stores workplaces

amp recreation areas close to residential areas are

effective in facilitating an increase in levels of physical

activity

--Majority of efforts to encourage walking to school involve

improving the routes rather than improving the location

of schools

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Improve access to public transportation

--Insufficient evidence exists to determine

effectiveness of transportation policies in

increasing the level of physical activity or

improving fitness

--1 study indicated that 29 of individuals who

walk to and from public transit achieve at least

30 minutes of daily physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Zone for mixed-use development

--Allows residential commercial institutional amp

other public land uses to be located in close

proximity to one another

--Studies using correlation analyses amp regression

models indicated that mixed land use was

associated with increased walking amp cycling

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance personal safety in areas where

persons are or could be physically active

--Cross-sectional studies have demonstrated a

negative relationship between crime rates andor

perceived safety amp physical activity in

neighborhoods

--Few intervention studies have evaluated the

impact of policies amp practices to improve

personal safety on physical activity

Geospatial Mapping Linking Urban

Environments to Health Risk

Measure association between environmental variables amp health risk factors

Assess relationships between variables at different levels of analysis

Used in conjunction with linear analyses

Our Community Environmental Model

of Obesity

Community Factors

Poverty

Crime

Grocery Quality

Restaurants

Parks

Sidewalks

Fast Food Outlets

Recreational

Facilities

Individual Factors

Dietary Intake

Physical Activity

Genetics

Family History

StressCoping

Eating Disorders

Psychological

Problems

Weight

Status

Chosen Neighborhoods

Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped

We then matched census-block groups within the income groups by population density and percentage of minority representation

One matched block group per income level was randomly selected

Prevalence of Obesity in

Block-Groups

0

5

10

15

20

25

30

35

40

45

50

Ag

e-a

dju

sted

Ob

esit

y P

rev

ale

nce

(

)

High-Income Low-Income

Age-standardized to the 1990 US Census

Density of Environmental Factors in the

Community Contributes to a ldquoToxicrdquo

Obesity Environment

0

2

4

6

8

10

12

14

16

18

Fast-food Convenience Store Bars

Den

sity

10

00

perso

ns

High-Income Low-Income

COMMUNITYrsquoS PERCEPTION OF SAFETY

0

5

10

15

20

25

30

35

40

Daytime Nighttime

Perc

en

t (

) F

eeli

ng

So

mew

hat

Safe

or

Un

safe

Low-Income High-Income

Percent Substandard (or worse) Housing

or Ground Conditions

of Residential Properties

0

10

20

30

Structural Grounds

Perc

en

t (

)

Low-Income High-Income

CONCLUSIONS

These data suggest that the higher

frequency of outlets providing

calorically-dense foods and alcohol may

contribute to greater obesity prevalence

in residents of low-income communities

More research is needed to thoroughly

document environmental determinants

of health and obesity

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

From 1994-1998 HUD randomly assigned

4498 women with children living in public

housing in high-poverty urban census

tracts to one of three groups (1) housing

vouchers redeemable only if they moved

to a low-poverty census tract (2)

unrestricted vouchers or (3) control group

(no vouchers)

Ludwig et al NEJM 201136516

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

10-12 year follow-up showed modest but

potentially important reductions in the

prevalence of extreme obesity amp diabetes in the

group moving from a neighborhood with high

poverty on one of low poverty compared to the

control group

No differences between the group receiving

traditional vouchers amp the control group

ldquoNeighborhoods matterrdquo

Ludwig et al NEJM 201136516

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance traffic safety in areas where

persons are or could be physically active

--Community-scale urban design amp land use policies to

promote physical activity including design components

to improve street lighting infrastructure projects to

increase safety of pedestrian street crossing and use of

traffic calming approaches such as speed humps amp

traffic circles are effective in increasing physical activity

--Both community-scale amp street-scale policies amp practices

are effective in increasing physical activity

Recommended Community Strategies Encourage Communities to Organize for Change

Participate in community coalitions or

partnerships to address obesity

--Little evidence is available to determine the

impact of community coalitions on obesity

prevention

--The presence of anti-smoking community

coalitions has been associated with lower rates

of tobacco consumption

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

$103 million awarded to 61 states and

communities including state amp local government

agencies tribes amp territories amp state amp local non-

profit organizations

To build capacity to implement changes for

community prevention efforts to ensure long-

term success

To implement evidence-based and practice-

based programs to improve health amp wellness

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Priority areas are

Tobacco-free living

Active living and healthy eating

Evidence-based quality clinical and other

preventive health services for prevention

and control of high blood pressure and

high cholesterol

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Applicants proposed specific activities in

line with their chosen priority areas in their

applications

Grantee activities will not be finalized until

plans are negotiated with CDC by early

2012

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Capacity-Building Award

The Confederated Tribes of The Chehalis

Reservation is receiving a $498663 planning

award to build capacity to support healthy

lifestyles among their tribal population of 1500

in Washington State

Work will target tobacco-free living active living

and healthy eating and quality clinical and other

healthy serviceswwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Implementation Award

Austin TX Dept of Health and Human Services

is receiving $1026158 to serve Travis County

(Austin) to expand efforts in tobacco-free living

active living and healthy eating quality clinical

and other preventive services social and

emotional wellness and healthy and safe

physical environmentswwwcdcgov1052011

Building sustainable healthy

communities Bottom line

Obesity is an environmental problem

Despite progress in genetic research public health advances only will occur when we take the environment seriously

Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment

Until we do this we will not make substantial progress in addressing the epidemic of obesity

Poston amp Foreyt Atherosclerosis 1999

Whatrsquos the best approach

Integrate all sectors of society into community

change interventions

Incorporate

Science amp Technology

Education

FamilyCommunity

Healthcare

Arts amp Entertainment

Law amp Politics

Commerce amp Trade

Sectors of Society

Arts amp Entertainm

ent

Commerce amp Trade

Education

FamilyCommunity

Healthcare

Law amp Politics

Science amp Technology

Project FIT rationale design and baseline characteristics of a school- and community-

based intervention to address physical activity and healthy eating among low-income

elementary school children

Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D

Oh HJ Orth J Randall S Mayfield K Holmes D

Source

Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu

Abstract

BACKGROUND

This paper describes Project FIT a collaboration between the public school system local

health systems physicians neighborhood associations businesses faith-based leaders

community agencies and university researchers to develop a multi-faceted approach to

promote physical activity and healthy eating toward the general goal of preventing and

reducing childhood obesity among children in Grand Rapids MI USA

METHODSDESIGN

There are four overall components to Project FIT school community social marketing and

school staff wellness - all that focus on 1) increasing access to safe and affordable physical

activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)

improving the affordability and availability of nutritious food in the neighborhoods surrounding

the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding

nutrition and physical activity among school staff parents and students 4) impacting the

culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging

dialogue among all community partners to leverage existing programs and introduce new

ones

Mean Changes in Lipid Profile

Averaged Over Four Years

DSE

Mean

ILI

Mean

P-value

HDL (mgdl) 197 367 lt00001

TG (mgdl) -1975 -2556 00006

LDL (mgdl) -1284 -1127 0009

LDL (mgdl)

(Adjusting for

medication use)

-922 -875 042

Look AHEAD Research Group Arch Int Med 2010

Percent () Completing Outcome

Measures at Years 1-4

Intervention Group

(ILI)

Year 1 971

Year 2 949

Year 3 940

Year 4 941

Comparison Group

(DSE)

Year 1 957

Year 2 935

Year 3 938

Year 4 931

Look AHEAD Summary

ILI had significantly greater improvements than DSE in all CVD risk factors averaged across 4 years (except LDL-C)

There may be long-term beneficial effects from this 4-year period in which ILI subjects have been exposed to lower CVD risk factors

Longer follow-ups will determine whether these lowered CVD risk factors can be maintained amp whether lifestyle intervention has positive effects on CVD morbidity amp mortality

Mary J

Female

White

56 years old at start of Look AHEAD

study

Past Medical History Type 2 diabetes

overweight diverticulosis arthritis

sleep apnea back pain

Mary J

bullLong term strugglesbull Helping youngest daughter with

personal issues and children

bull Rotator cuff problems

bull Degenerative disks in back

bull Rheumatoid arthritis

bull Diabetes

bull Physically demanding job

bull Financial struggles

Pounds

Years

82007 grandkids enter pre-school

Catherine L

Female

White

47 years old at start of Look AHEAD

study

Past Medical History Type 2 diabetes

overweight high blood pressure

hypothyroidism back pain

Catherine L

Long term struggles

bull Motherrsquos declining health and death

bull Multiple serious injuries

bull Sudden death of sister

bull Death of step-father

bull Declining economy

bull Children living at home

Pounds

Years

Realistic Management Goals

5-10 weight loss

Health energy and fitness

Well-being and self-esteem

Mood and appearance

Functional and recreational

activity

Key Elements

Focus on health and energy

Food and physical activity diaries

Gradual increase in physical activity

Gradual reduction in dietary fat

No feelings of food deprivation

Social support groups

Recommended Strategies for Building

Sustainable Healthy Communities

Overview from USA

Promote the availability of affordable healthy

food and beverages

Support healthy food and beverage choices

Encourage breastfeeding

Encourage physical activity or limit sedentary

activity among children amp youth

Create safe communities that support physical

activity

Encourage communities to organize for change

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Increase the availability of healthier food and

beverage choices in public service venues (eg

schools city amp county buildings etc)

--Insufficient evidence in school-based programs

--Associations suggest availability amp increased

consumption

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve availability of affordable healthier

food amp beverage choices in public service

venues

--Reducing the cost of healthier foods

increases their purchase

--Providing coupons redeemable for

healthier foods increases their purchase

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve geographic availability of

supermarkets in underserved areas

-- Greater access to nearby supermarkets is

associated with healthier eating behaviors

-- Increasing the number of supermarkets in

underserved neighborhoods increased

real estate values increased economic

activity amp employment amp resulted in lower

food prices

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Provide incentives to food retailers to locate in

andor offer healthier food choices in

underserved areas

-- Presence of retail venues that provide healthier

foods is associated with better nutrition

-- Greater availability of supermarkets was

associated with lower adolescent BMI scores

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Improve availability of mechanisms for

purchasing foods from farms

--Evidence supporting a direct link between

purchasing food from farms amp improved diet is

limited

--Two studies of initiatives to encourage

participation in farmersrsquo market showed

increased intention to eat more fruits amp

vegetables but no direct evidence

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Provide incentives for the production

distribution and procurement of foods from local

farms

--No evidence has been published to link local

food production amp health outcomes

--There is a current study exploring the potential

nutritional amp health benefits of eating locally

grown foods

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Restrict availability of less healthy foods amp

beverages in public service venues

--No peer-reviewed studies examined the impact

designed to restrict availability of less healthy

foods in public service venues

--21 states have policies that restrict the sale of

competitive foods in schools beyond USDA

regulations however no studies have evaluated

the impact of the policies

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Institute smaller portion size options in public

service venues

--Evidence is lacking to demonstrate effectiveness

of population-based interventions aimed at

reducing portion sizes in public service venues

--Evidence from clinical studies in laboratories

demonstrates decreasing portion sizes

decreases energy intake

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Limit advertisements of less healthy foods amp

beverages

--Little evidence is available regarding the impact

of restricting advertising on purchasing amp

consumption of less healthy foods

--Cross-sectional time-series studies of tobacco-

control efforts suggest an association between

advertising bans amp decreased tobacco

consumption

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Discourage consumption of sugar-sweetened

beverages

--One longitudinal study of a school-based

intervention among Native-American high school

students showed a substantial reduction in

sugar-sweetened beverages over a 3-year

period

--A RCT of a home-based intervention that

eliminated sugar-sweetened beverages showed

reduction in BMI scores

Recommended Community Strategies Strategies to encourage breastfeeding

Increase support for breastfeeding

--Evidence directly linking environmental

interventions that support breastfeeding with

obesity-related outcomes is lacking

--Epidemiologic studies indicate that breastfeeding

helps prevent pediatric obesity

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Require physical education in schools

--14 studies have demonstrated that school-based

PE was effective in increasing levels of physical

activity and improving physical fitness

--Minimum of 150 minwk in elementary schools

225 minwk in middle schools and high schools

throughout the school year as recommended by

NASPE

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Increase opportunities for extracurricular

physical activity

--Participation in after-school programs increased

studentsrsquo level of physical activity amp improved

obesity-related outcomes (improved CV fitness

reduced body fat)

--2 pilot studies providing extracurricular physical

activity showed increased levels of PA amp

decreased sedentary behavior

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Reduce screen time in public service venues

--A school-based RCT indicated that children who

reduced their television videotape amp video

game use had significant decrease in BMI tricep

skin fold thickness amp waist circumference

compared to controls

--Spending less time watching television is

associated with increased physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Improve access to outdoor recreational

facilities

--Review of 108 studies indicated that access to facilities

and programs for recreation near their homes amp time

spent outdoors correlated positively with increased

physical activity among childrenamp adults

--Perceptions that footpaths are safe for walking was

significantly associated with adults being classified as

physically active at a level sufficient for health benefits

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting

bicycling

--Longitudinal intervention studies have

demonstrated that improving bicycling

infrastructure is associated with increased

frequency of bicycling

--Cross-sectional studies indicated a significant

association between bicycling infrastructure amp

frequency of biking

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting walking

--Reviews of cross-sectional studies of

environmental correlates of physical activity amp

walking generally find a positive association

between infrastructure supportive of walking amp

physical activity

--Identifying amp creating safe routes to school

together with educational components

increased the number of students walking to

school

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Locating schools within easy walking

distance of residential areas

--Community-scale urban design amp land use policies amp

practices including locating schools stores workplaces

amp recreation areas close to residential areas are

effective in facilitating an increase in levels of physical

activity

--Majority of efforts to encourage walking to school involve

improving the routes rather than improving the location

of schools

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Improve access to public transportation

--Insufficient evidence exists to determine

effectiveness of transportation policies in

increasing the level of physical activity or

improving fitness

--1 study indicated that 29 of individuals who

walk to and from public transit achieve at least

30 minutes of daily physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Zone for mixed-use development

--Allows residential commercial institutional amp

other public land uses to be located in close

proximity to one another

--Studies using correlation analyses amp regression

models indicated that mixed land use was

associated with increased walking amp cycling

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance personal safety in areas where

persons are or could be physically active

--Cross-sectional studies have demonstrated a

negative relationship between crime rates andor

perceived safety amp physical activity in

neighborhoods

--Few intervention studies have evaluated the

impact of policies amp practices to improve

personal safety on physical activity

Geospatial Mapping Linking Urban

Environments to Health Risk

Measure association between environmental variables amp health risk factors

Assess relationships between variables at different levels of analysis

Used in conjunction with linear analyses

Our Community Environmental Model

of Obesity

Community Factors

Poverty

Crime

Grocery Quality

Restaurants

Parks

Sidewalks

Fast Food Outlets

Recreational

Facilities

Individual Factors

Dietary Intake

Physical Activity

Genetics

Family History

StressCoping

Eating Disorders

Psychological

Problems

Weight

Status

Chosen Neighborhoods

Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped

We then matched census-block groups within the income groups by population density and percentage of minority representation

One matched block group per income level was randomly selected

Prevalence of Obesity in

Block-Groups

0

5

10

15

20

25

30

35

40

45

50

Ag

e-a

dju

sted

Ob

esit

y P

rev

ale

nce

(

)

High-Income Low-Income

Age-standardized to the 1990 US Census

Density of Environmental Factors in the

Community Contributes to a ldquoToxicrdquo

Obesity Environment

0

2

4

6

8

10

12

14

16

18

Fast-food Convenience Store Bars

Den

sity

10

00

perso

ns

High-Income Low-Income

COMMUNITYrsquoS PERCEPTION OF SAFETY

0

5

10

15

20

25

30

35

40

Daytime Nighttime

Perc

en

t (

) F

eeli

ng

So

mew

hat

Safe

or

Un

safe

Low-Income High-Income

Percent Substandard (or worse) Housing

or Ground Conditions

of Residential Properties

0

10

20

30

Structural Grounds

Perc

en

t (

)

Low-Income High-Income

CONCLUSIONS

These data suggest that the higher

frequency of outlets providing

calorically-dense foods and alcohol may

contribute to greater obesity prevalence

in residents of low-income communities

More research is needed to thoroughly

document environmental determinants

of health and obesity

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

From 1994-1998 HUD randomly assigned

4498 women with children living in public

housing in high-poverty urban census

tracts to one of three groups (1) housing

vouchers redeemable only if they moved

to a low-poverty census tract (2)

unrestricted vouchers or (3) control group

(no vouchers)

Ludwig et al NEJM 201136516

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

10-12 year follow-up showed modest but

potentially important reductions in the

prevalence of extreme obesity amp diabetes in the

group moving from a neighborhood with high

poverty on one of low poverty compared to the

control group

No differences between the group receiving

traditional vouchers amp the control group

ldquoNeighborhoods matterrdquo

Ludwig et al NEJM 201136516

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance traffic safety in areas where

persons are or could be physically active

--Community-scale urban design amp land use policies to

promote physical activity including design components

to improve street lighting infrastructure projects to

increase safety of pedestrian street crossing and use of

traffic calming approaches such as speed humps amp

traffic circles are effective in increasing physical activity

--Both community-scale amp street-scale policies amp practices

are effective in increasing physical activity

Recommended Community Strategies Encourage Communities to Organize for Change

Participate in community coalitions or

partnerships to address obesity

--Little evidence is available to determine the

impact of community coalitions on obesity

prevention

--The presence of anti-smoking community

coalitions has been associated with lower rates

of tobacco consumption

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

$103 million awarded to 61 states and

communities including state amp local government

agencies tribes amp territories amp state amp local non-

profit organizations

To build capacity to implement changes for

community prevention efforts to ensure long-

term success

To implement evidence-based and practice-

based programs to improve health amp wellness

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Priority areas are

Tobacco-free living

Active living and healthy eating

Evidence-based quality clinical and other

preventive health services for prevention

and control of high blood pressure and

high cholesterol

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Applicants proposed specific activities in

line with their chosen priority areas in their

applications

Grantee activities will not be finalized until

plans are negotiated with CDC by early

2012

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Capacity-Building Award

The Confederated Tribes of The Chehalis

Reservation is receiving a $498663 planning

award to build capacity to support healthy

lifestyles among their tribal population of 1500

in Washington State

Work will target tobacco-free living active living

and healthy eating and quality clinical and other

healthy serviceswwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Implementation Award

Austin TX Dept of Health and Human Services

is receiving $1026158 to serve Travis County

(Austin) to expand efforts in tobacco-free living

active living and healthy eating quality clinical

and other preventive services social and

emotional wellness and healthy and safe

physical environmentswwwcdcgov1052011

Building sustainable healthy

communities Bottom line

Obesity is an environmental problem

Despite progress in genetic research public health advances only will occur when we take the environment seriously

Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment

Until we do this we will not make substantial progress in addressing the epidemic of obesity

Poston amp Foreyt Atherosclerosis 1999

Whatrsquos the best approach

Integrate all sectors of society into community

change interventions

Incorporate

Science amp Technology

Education

FamilyCommunity

Healthcare

Arts amp Entertainment

Law amp Politics

Commerce amp Trade

Sectors of Society

Arts amp Entertainm

ent

Commerce amp Trade

Education

FamilyCommunity

Healthcare

Law amp Politics

Science amp Technology

Project FIT rationale design and baseline characteristics of a school- and community-

based intervention to address physical activity and healthy eating among low-income

elementary school children

Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D

Oh HJ Orth J Randall S Mayfield K Holmes D

Source

Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu

Abstract

BACKGROUND

This paper describes Project FIT a collaboration between the public school system local

health systems physicians neighborhood associations businesses faith-based leaders

community agencies and university researchers to develop a multi-faceted approach to

promote physical activity and healthy eating toward the general goal of preventing and

reducing childhood obesity among children in Grand Rapids MI USA

METHODSDESIGN

There are four overall components to Project FIT school community social marketing and

school staff wellness - all that focus on 1) increasing access to safe and affordable physical

activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)

improving the affordability and availability of nutritious food in the neighborhoods surrounding

the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding

nutrition and physical activity among school staff parents and students 4) impacting the

culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging

dialogue among all community partners to leverage existing programs and introduce new

ones

Percent () Completing Outcome

Measures at Years 1-4

Intervention Group

(ILI)

Year 1 971

Year 2 949

Year 3 940

Year 4 941

Comparison Group

(DSE)

Year 1 957

Year 2 935

Year 3 938

Year 4 931

Look AHEAD Summary

ILI had significantly greater improvements than DSE in all CVD risk factors averaged across 4 years (except LDL-C)

There may be long-term beneficial effects from this 4-year period in which ILI subjects have been exposed to lower CVD risk factors

Longer follow-ups will determine whether these lowered CVD risk factors can be maintained amp whether lifestyle intervention has positive effects on CVD morbidity amp mortality

Mary J

Female

White

56 years old at start of Look AHEAD

study

Past Medical History Type 2 diabetes

overweight diverticulosis arthritis

sleep apnea back pain

Mary J

bullLong term strugglesbull Helping youngest daughter with

personal issues and children

bull Rotator cuff problems

bull Degenerative disks in back

bull Rheumatoid arthritis

bull Diabetes

bull Physically demanding job

bull Financial struggles

Pounds

Years

82007 grandkids enter pre-school

Catherine L

Female

White

47 years old at start of Look AHEAD

study

Past Medical History Type 2 diabetes

overweight high blood pressure

hypothyroidism back pain

Catherine L

Long term struggles

bull Motherrsquos declining health and death

bull Multiple serious injuries

bull Sudden death of sister

bull Death of step-father

bull Declining economy

bull Children living at home

Pounds

Years

Realistic Management Goals

5-10 weight loss

Health energy and fitness

Well-being and self-esteem

Mood and appearance

Functional and recreational

activity

Key Elements

Focus on health and energy

Food and physical activity diaries

Gradual increase in physical activity

Gradual reduction in dietary fat

No feelings of food deprivation

Social support groups

Recommended Strategies for Building

Sustainable Healthy Communities

Overview from USA

Promote the availability of affordable healthy

food and beverages

Support healthy food and beverage choices

Encourage breastfeeding

Encourage physical activity or limit sedentary

activity among children amp youth

Create safe communities that support physical

activity

Encourage communities to organize for change

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Increase the availability of healthier food and

beverage choices in public service venues (eg

schools city amp county buildings etc)

--Insufficient evidence in school-based programs

--Associations suggest availability amp increased

consumption

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve availability of affordable healthier

food amp beverage choices in public service

venues

--Reducing the cost of healthier foods

increases their purchase

--Providing coupons redeemable for

healthier foods increases their purchase

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve geographic availability of

supermarkets in underserved areas

-- Greater access to nearby supermarkets is

associated with healthier eating behaviors

-- Increasing the number of supermarkets in

underserved neighborhoods increased

real estate values increased economic

activity amp employment amp resulted in lower

food prices

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Provide incentives to food retailers to locate in

andor offer healthier food choices in

underserved areas

-- Presence of retail venues that provide healthier

foods is associated with better nutrition

-- Greater availability of supermarkets was

associated with lower adolescent BMI scores

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Improve availability of mechanisms for

purchasing foods from farms

--Evidence supporting a direct link between

purchasing food from farms amp improved diet is

limited

--Two studies of initiatives to encourage

participation in farmersrsquo market showed

increased intention to eat more fruits amp

vegetables but no direct evidence

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Provide incentives for the production

distribution and procurement of foods from local

farms

--No evidence has been published to link local

food production amp health outcomes

--There is a current study exploring the potential

nutritional amp health benefits of eating locally

grown foods

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Restrict availability of less healthy foods amp

beverages in public service venues

--No peer-reviewed studies examined the impact

designed to restrict availability of less healthy

foods in public service venues

--21 states have policies that restrict the sale of

competitive foods in schools beyond USDA

regulations however no studies have evaluated

the impact of the policies

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Institute smaller portion size options in public

service venues

--Evidence is lacking to demonstrate effectiveness

of population-based interventions aimed at

reducing portion sizes in public service venues

--Evidence from clinical studies in laboratories

demonstrates decreasing portion sizes

decreases energy intake

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Limit advertisements of less healthy foods amp

beverages

--Little evidence is available regarding the impact

of restricting advertising on purchasing amp

consumption of less healthy foods

--Cross-sectional time-series studies of tobacco-

control efforts suggest an association between

advertising bans amp decreased tobacco

consumption

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Discourage consumption of sugar-sweetened

beverages

--One longitudinal study of a school-based

intervention among Native-American high school

students showed a substantial reduction in

sugar-sweetened beverages over a 3-year

period

--A RCT of a home-based intervention that

eliminated sugar-sweetened beverages showed

reduction in BMI scores

Recommended Community Strategies Strategies to encourage breastfeeding

Increase support for breastfeeding

--Evidence directly linking environmental

interventions that support breastfeeding with

obesity-related outcomes is lacking

--Epidemiologic studies indicate that breastfeeding

helps prevent pediatric obesity

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Require physical education in schools

--14 studies have demonstrated that school-based

PE was effective in increasing levels of physical

activity and improving physical fitness

--Minimum of 150 minwk in elementary schools

225 minwk in middle schools and high schools

throughout the school year as recommended by

NASPE

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Increase opportunities for extracurricular

physical activity

--Participation in after-school programs increased

studentsrsquo level of physical activity amp improved

obesity-related outcomes (improved CV fitness

reduced body fat)

--2 pilot studies providing extracurricular physical

activity showed increased levels of PA amp

decreased sedentary behavior

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Reduce screen time in public service venues

--A school-based RCT indicated that children who

reduced their television videotape amp video

game use had significant decrease in BMI tricep

skin fold thickness amp waist circumference

compared to controls

--Spending less time watching television is

associated with increased physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Improve access to outdoor recreational

facilities

--Review of 108 studies indicated that access to facilities

and programs for recreation near their homes amp time

spent outdoors correlated positively with increased

physical activity among childrenamp adults

--Perceptions that footpaths are safe for walking was

significantly associated with adults being classified as

physically active at a level sufficient for health benefits

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting

bicycling

--Longitudinal intervention studies have

demonstrated that improving bicycling

infrastructure is associated with increased

frequency of bicycling

--Cross-sectional studies indicated a significant

association between bicycling infrastructure amp

frequency of biking

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting walking

--Reviews of cross-sectional studies of

environmental correlates of physical activity amp

walking generally find a positive association

between infrastructure supportive of walking amp

physical activity

--Identifying amp creating safe routes to school

together with educational components

increased the number of students walking to

school

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Locating schools within easy walking

distance of residential areas

--Community-scale urban design amp land use policies amp

practices including locating schools stores workplaces

amp recreation areas close to residential areas are

effective in facilitating an increase in levels of physical

activity

--Majority of efforts to encourage walking to school involve

improving the routes rather than improving the location

of schools

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Improve access to public transportation

--Insufficient evidence exists to determine

effectiveness of transportation policies in

increasing the level of physical activity or

improving fitness

--1 study indicated that 29 of individuals who

walk to and from public transit achieve at least

30 minutes of daily physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Zone for mixed-use development

--Allows residential commercial institutional amp

other public land uses to be located in close

proximity to one another

--Studies using correlation analyses amp regression

models indicated that mixed land use was

associated with increased walking amp cycling

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance personal safety in areas where

persons are or could be physically active

--Cross-sectional studies have demonstrated a

negative relationship between crime rates andor

perceived safety amp physical activity in

neighborhoods

--Few intervention studies have evaluated the

impact of policies amp practices to improve

personal safety on physical activity

Geospatial Mapping Linking Urban

Environments to Health Risk

Measure association between environmental variables amp health risk factors

Assess relationships between variables at different levels of analysis

Used in conjunction with linear analyses

Our Community Environmental Model

of Obesity

Community Factors

Poverty

Crime

Grocery Quality

Restaurants

Parks

Sidewalks

Fast Food Outlets

Recreational

Facilities

Individual Factors

Dietary Intake

Physical Activity

Genetics

Family History

StressCoping

Eating Disorders

Psychological

Problems

Weight

Status

Chosen Neighborhoods

Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped

We then matched census-block groups within the income groups by population density and percentage of minority representation

One matched block group per income level was randomly selected

Prevalence of Obesity in

Block-Groups

0

5

10

15

20

25

30

35

40

45

50

Ag

e-a

dju

sted

Ob

esit

y P

rev

ale

nce

(

)

High-Income Low-Income

Age-standardized to the 1990 US Census

Density of Environmental Factors in the

Community Contributes to a ldquoToxicrdquo

Obesity Environment

0

2

4

6

8

10

12

14

16

18

Fast-food Convenience Store Bars

Den

sity

10

00

perso

ns

High-Income Low-Income

COMMUNITYrsquoS PERCEPTION OF SAFETY

0

5

10

15

20

25

30

35

40

Daytime Nighttime

Perc

en

t (

) F

eeli

ng

So

mew

hat

Safe

or

Un

safe

Low-Income High-Income

Percent Substandard (or worse) Housing

or Ground Conditions

of Residential Properties

0

10

20

30

Structural Grounds

Perc

en

t (

)

Low-Income High-Income

CONCLUSIONS

These data suggest that the higher

frequency of outlets providing

calorically-dense foods and alcohol may

contribute to greater obesity prevalence

in residents of low-income communities

More research is needed to thoroughly

document environmental determinants

of health and obesity

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

From 1994-1998 HUD randomly assigned

4498 women with children living in public

housing in high-poverty urban census

tracts to one of three groups (1) housing

vouchers redeemable only if they moved

to a low-poverty census tract (2)

unrestricted vouchers or (3) control group

(no vouchers)

Ludwig et al NEJM 201136516

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

10-12 year follow-up showed modest but

potentially important reductions in the

prevalence of extreme obesity amp diabetes in the

group moving from a neighborhood with high

poverty on one of low poverty compared to the

control group

No differences between the group receiving

traditional vouchers amp the control group

ldquoNeighborhoods matterrdquo

Ludwig et al NEJM 201136516

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance traffic safety in areas where

persons are or could be physically active

--Community-scale urban design amp land use policies to

promote physical activity including design components

to improve street lighting infrastructure projects to

increase safety of pedestrian street crossing and use of

traffic calming approaches such as speed humps amp

traffic circles are effective in increasing physical activity

--Both community-scale amp street-scale policies amp practices

are effective in increasing physical activity

Recommended Community Strategies Encourage Communities to Organize for Change

Participate in community coalitions or

partnerships to address obesity

--Little evidence is available to determine the

impact of community coalitions on obesity

prevention

--The presence of anti-smoking community

coalitions has been associated with lower rates

of tobacco consumption

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

$103 million awarded to 61 states and

communities including state amp local government

agencies tribes amp territories amp state amp local non-

profit organizations

To build capacity to implement changes for

community prevention efforts to ensure long-

term success

To implement evidence-based and practice-

based programs to improve health amp wellness

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Priority areas are

Tobacco-free living

Active living and healthy eating

Evidence-based quality clinical and other

preventive health services for prevention

and control of high blood pressure and

high cholesterol

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Applicants proposed specific activities in

line with their chosen priority areas in their

applications

Grantee activities will not be finalized until

plans are negotiated with CDC by early

2012

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Capacity-Building Award

The Confederated Tribes of The Chehalis

Reservation is receiving a $498663 planning

award to build capacity to support healthy

lifestyles among their tribal population of 1500

in Washington State

Work will target tobacco-free living active living

and healthy eating and quality clinical and other

healthy serviceswwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Implementation Award

Austin TX Dept of Health and Human Services

is receiving $1026158 to serve Travis County

(Austin) to expand efforts in tobacco-free living

active living and healthy eating quality clinical

and other preventive services social and

emotional wellness and healthy and safe

physical environmentswwwcdcgov1052011

Building sustainable healthy

communities Bottom line

Obesity is an environmental problem

Despite progress in genetic research public health advances only will occur when we take the environment seriously

Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment

Until we do this we will not make substantial progress in addressing the epidemic of obesity

Poston amp Foreyt Atherosclerosis 1999

Whatrsquos the best approach

Integrate all sectors of society into community

change interventions

Incorporate

Science amp Technology

Education

FamilyCommunity

Healthcare

Arts amp Entertainment

Law amp Politics

Commerce amp Trade

Sectors of Society

Arts amp Entertainm

ent

Commerce amp Trade

Education

FamilyCommunity

Healthcare

Law amp Politics

Science amp Technology

Project FIT rationale design and baseline characteristics of a school- and community-

based intervention to address physical activity and healthy eating among low-income

elementary school children

Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D

Oh HJ Orth J Randall S Mayfield K Holmes D

Source

Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu

Abstract

BACKGROUND

This paper describes Project FIT a collaboration between the public school system local

health systems physicians neighborhood associations businesses faith-based leaders

community agencies and university researchers to develop a multi-faceted approach to

promote physical activity and healthy eating toward the general goal of preventing and

reducing childhood obesity among children in Grand Rapids MI USA

METHODSDESIGN

There are four overall components to Project FIT school community social marketing and

school staff wellness - all that focus on 1) increasing access to safe and affordable physical

activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)

improving the affordability and availability of nutritious food in the neighborhoods surrounding

the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding

nutrition and physical activity among school staff parents and students 4) impacting the

culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging

dialogue among all community partners to leverage existing programs and introduce new

ones

Look AHEAD Summary

ILI had significantly greater improvements than DSE in all CVD risk factors averaged across 4 years (except LDL-C)

There may be long-term beneficial effects from this 4-year period in which ILI subjects have been exposed to lower CVD risk factors

Longer follow-ups will determine whether these lowered CVD risk factors can be maintained amp whether lifestyle intervention has positive effects on CVD morbidity amp mortality

Mary J

Female

White

56 years old at start of Look AHEAD

study

Past Medical History Type 2 diabetes

overweight diverticulosis arthritis

sleep apnea back pain

Mary J

bullLong term strugglesbull Helping youngest daughter with

personal issues and children

bull Rotator cuff problems

bull Degenerative disks in back

bull Rheumatoid arthritis

bull Diabetes

bull Physically demanding job

bull Financial struggles

Pounds

Years

82007 grandkids enter pre-school

Catherine L

Female

White

47 years old at start of Look AHEAD

study

Past Medical History Type 2 diabetes

overweight high blood pressure

hypothyroidism back pain

Catherine L

Long term struggles

bull Motherrsquos declining health and death

bull Multiple serious injuries

bull Sudden death of sister

bull Death of step-father

bull Declining economy

bull Children living at home

Pounds

Years

Realistic Management Goals

5-10 weight loss

Health energy and fitness

Well-being and self-esteem

Mood and appearance

Functional and recreational

activity

Key Elements

Focus on health and energy

Food and physical activity diaries

Gradual increase in physical activity

Gradual reduction in dietary fat

No feelings of food deprivation

Social support groups

Recommended Strategies for Building

Sustainable Healthy Communities

Overview from USA

Promote the availability of affordable healthy

food and beverages

Support healthy food and beverage choices

Encourage breastfeeding

Encourage physical activity or limit sedentary

activity among children amp youth

Create safe communities that support physical

activity

Encourage communities to organize for change

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Increase the availability of healthier food and

beverage choices in public service venues (eg

schools city amp county buildings etc)

--Insufficient evidence in school-based programs

--Associations suggest availability amp increased

consumption

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve availability of affordable healthier

food amp beverage choices in public service

venues

--Reducing the cost of healthier foods

increases their purchase

--Providing coupons redeemable for

healthier foods increases their purchase

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve geographic availability of

supermarkets in underserved areas

-- Greater access to nearby supermarkets is

associated with healthier eating behaviors

-- Increasing the number of supermarkets in

underserved neighborhoods increased

real estate values increased economic

activity amp employment amp resulted in lower

food prices

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Provide incentives to food retailers to locate in

andor offer healthier food choices in

underserved areas

-- Presence of retail venues that provide healthier

foods is associated with better nutrition

-- Greater availability of supermarkets was

associated with lower adolescent BMI scores

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Improve availability of mechanisms for

purchasing foods from farms

--Evidence supporting a direct link between

purchasing food from farms amp improved diet is

limited

--Two studies of initiatives to encourage

participation in farmersrsquo market showed

increased intention to eat more fruits amp

vegetables but no direct evidence

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Provide incentives for the production

distribution and procurement of foods from local

farms

--No evidence has been published to link local

food production amp health outcomes

--There is a current study exploring the potential

nutritional amp health benefits of eating locally

grown foods

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Restrict availability of less healthy foods amp

beverages in public service venues

--No peer-reviewed studies examined the impact

designed to restrict availability of less healthy

foods in public service venues

--21 states have policies that restrict the sale of

competitive foods in schools beyond USDA

regulations however no studies have evaluated

the impact of the policies

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Institute smaller portion size options in public

service venues

--Evidence is lacking to demonstrate effectiveness

of population-based interventions aimed at

reducing portion sizes in public service venues

--Evidence from clinical studies in laboratories

demonstrates decreasing portion sizes

decreases energy intake

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Limit advertisements of less healthy foods amp

beverages

--Little evidence is available regarding the impact

of restricting advertising on purchasing amp

consumption of less healthy foods

--Cross-sectional time-series studies of tobacco-

control efforts suggest an association between

advertising bans amp decreased tobacco

consumption

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Discourage consumption of sugar-sweetened

beverages

--One longitudinal study of a school-based

intervention among Native-American high school

students showed a substantial reduction in

sugar-sweetened beverages over a 3-year

period

--A RCT of a home-based intervention that

eliminated sugar-sweetened beverages showed

reduction in BMI scores

Recommended Community Strategies Strategies to encourage breastfeeding

Increase support for breastfeeding

--Evidence directly linking environmental

interventions that support breastfeeding with

obesity-related outcomes is lacking

--Epidemiologic studies indicate that breastfeeding

helps prevent pediatric obesity

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Require physical education in schools

--14 studies have demonstrated that school-based

PE was effective in increasing levels of physical

activity and improving physical fitness

--Minimum of 150 minwk in elementary schools

225 minwk in middle schools and high schools

throughout the school year as recommended by

NASPE

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Increase opportunities for extracurricular

physical activity

--Participation in after-school programs increased

studentsrsquo level of physical activity amp improved

obesity-related outcomes (improved CV fitness

reduced body fat)

--2 pilot studies providing extracurricular physical

activity showed increased levels of PA amp

decreased sedentary behavior

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Reduce screen time in public service venues

--A school-based RCT indicated that children who

reduced their television videotape amp video

game use had significant decrease in BMI tricep

skin fold thickness amp waist circumference

compared to controls

--Spending less time watching television is

associated with increased physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Improve access to outdoor recreational

facilities

--Review of 108 studies indicated that access to facilities

and programs for recreation near their homes amp time

spent outdoors correlated positively with increased

physical activity among childrenamp adults

--Perceptions that footpaths are safe for walking was

significantly associated with adults being classified as

physically active at a level sufficient for health benefits

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting

bicycling

--Longitudinal intervention studies have

demonstrated that improving bicycling

infrastructure is associated with increased

frequency of bicycling

--Cross-sectional studies indicated a significant

association between bicycling infrastructure amp

frequency of biking

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting walking

--Reviews of cross-sectional studies of

environmental correlates of physical activity amp

walking generally find a positive association

between infrastructure supportive of walking amp

physical activity

--Identifying amp creating safe routes to school

together with educational components

increased the number of students walking to

school

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Locating schools within easy walking

distance of residential areas

--Community-scale urban design amp land use policies amp

practices including locating schools stores workplaces

amp recreation areas close to residential areas are

effective in facilitating an increase in levels of physical

activity

--Majority of efforts to encourage walking to school involve

improving the routes rather than improving the location

of schools

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Improve access to public transportation

--Insufficient evidence exists to determine

effectiveness of transportation policies in

increasing the level of physical activity or

improving fitness

--1 study indicated that 29 of individuals who

walk to and from public transit achieve at least

30 minutes of daily physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Zone for mixed-use development

--Allows residential commercial institutional amp

other public land uses to be located in close

proximity to one another

--Studies using correlation analyses amp regression

models indicated that mixed land use was

associated with increased walking amp cycling

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance personal safety in areas where

persons are or could be physically active

--Cross-sectional studies have demonstrated a

negative relationship between crime rates andor

perceived safety amp physical activity in

neighborhoods

--Few intervention studies have evaluated the

impact of policies amp practices to improve

personal safety on physical activity

Geospatial Mapping Linking Urban

Environments to Health Risk

Measure association between environmental variables amp health risk factors

Assess relationships between variables at different levels of analysis

Used in conjunction with linear analyses

Our Community Environmental Model

of Obesity

Community Factors

Poverty

Crime

Grocery Quality

Restaurants

Parks

Sidewalks

Fast Food Outlets

Recreational

Facilities

Individual Factors

Dietary Intake

Physical Activity

Genetics

Family History

StressCoping

Eating Disorders

Psychological

Problems

Weight

Status

Chosen Neighborhoods

Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped

We then matched census-block groups within the income groups by population density and percentage of minority representation

One matched block group per income level was randomly selected

Prevalence of Obesity in

Block-Groups

0

5

10

15

20

25

30

35

40

45

50

Ag

e-a

dju

sted

Ob

esit

y P

rev

ale

nce

(

)

High-Income Low-Income

Age-standardized to the 1990 US Census

Density of Environmental Factors in the

Community Contributes to a ldquoToxicrdquo

Obesity Environment

0

2

4

6

8

10

12

14

16

18

Fast-food Convenience Store Bars

Den

sity

10

00

perso

ns

High-Income Low-Income

COMMUNITYrsquoS PERCEPTION OF SAFETY

0

5

10

15

20

25

30

35

40

Daytime Nighttime

Perc

en

t (

) F

eeli

ng

So

mew

hat

Safe

or

Un

safe

Low-Income High-Income

Percent Substandard (or worse) Housing

or Ground Conditions

of Residential Properties

0

10

20

30

Structural Grounds

Perc

en

t (

)

Low-Income High-Income

CONCLUSIONS

These data suggest that the higher

frequency of outlets providing

calorically-dense foods and alcohol may

contribute to greater obesity prevalence

in residents of low-income communities

More research is needed to thoroughly

document environmental determinants

of health and obesity

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

From 1994-1998 HUD randomly assigned

4498 women with children living in public

housing in high-poverty urban census

tracts to one of three groups (1) housing

vouchers redeemable only if they moved

to a low-poverty census tract (2)

unrestricted vouchers or (3) control group

(no vouchers)

Ludwig et al NEJM 201136516

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

10-12 year follow-up showed modest but

potentially important reductions in the

prevalence of extreme obesity amp diabetes in the

group moving from a neighborhood with high

poverty on one of low poverty compared to the

control group

No differences between the group receiving

traditional vouchers amp the control group

ldquoNeighborhoods matterrdquo

Ludwig et al NEJM 201136516

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance traffic safety in areas where

persons are or could be physically active

--Community-scale urban design amp land use policies to

promote physical activity including design components

to improve street lighting infrastructure projects to

increase safety of pedestrian street crossing and use of

traffic calming approaches such as speed humps amp

traffic circles are effective in increasing physical activity

--Both community-scale amp street-scale policies amp practices

are effective in increasing physical activity

Recommended Community Strategies Encourage Communities to Organize for Change

Participate in community coalitions or

partnerships to address obesity

--Little evidence is available to determine the

impact of community coalitions on obesity

prevention

--The presence of anti-smoking community

coalitions has been associated with lower rates

of tobacco consumption

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

$103 million awarded to 61 states and

communities including state amp local government

agencies tribes amp territories amp state amp local non-

profit organizations

To build capacity to implement changes for

community prevention efforts to ensure long-

term success

To implement evidence-based and practice-

based programs to improve health amp wellness

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Priority areas are

Tobacco-free living

Active living and healthy eating

Evidence-based quality clinical and other

preventive health services for prevention

and control of high blood pressure and

high cholesterol

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Applicants proposed specific activities in

line with their chosen priority areas in their

applications

Grantee activities will not be finalized until

plans are negotiated with CDC by early

2012

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Capacity-Building Award

The Confederated Tribes of The Chehalis

Reservation is receiving a $498663 planning

award to build capacity to support healthy

lifestyles among their tribal population of 1500

in Washington State

Work will target tobacco-free living active living

and healthy eating and quality clinical and other

healthy serviceswwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Implementation Award

Austin TX Dept of Health and Human Services

is receiving $1026158 to serve Travis County

(Austin) to expand efforts in tobacco-free living

active living and healthy eating quality clinical

and other preventive services social and

emotional wellness and healthy and safe

physical environmentswwwcdcgov1052011

Building sustainable healthy

communities Bottom line

Obesity is an environmental problem

Despite progress in genetic research public health advances only will occur when we take the environment seriously

Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment

Until we do this we will not make substantial progress in addressing the epidemic of obesity

Poston amp Foreyt Atherosclerosis 1999

Whatrsquos the best approach

Integrate all sectors of society into community

change interventions

Incorporate

Science amp Technology

Education

FamilyCommunity

Healthcare

Arts amp Entertainment

Law amp Politics

Commerce amp Trade

Sectors of Society

Arts amp Entertainm

ent

Commerce amp Trade

Education

FamilyCommunity

Healthcare

Law amp Politics

Science amp Technology

Project FIT rationale design and baseline characteristics of a school- and community-

based intervention to address physical activity and healthy eating among low-income

elementary school children

Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D

Oh HJ Orth J Randall S Mayfield K Holmes D

Source

Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu

Abstract

BACKGROUND

This paper describes Project FIT a collaboration between the public school system local

health systems physicians neighborhood associations businesses faith-based leaders

community agencies and university researchers to develop a multi-faceted approach to

promote physical activity and healthy eating toward the general goal of preventing and

reducing childhood obesity among children in Grand Rapids MI USA

METHODSDESIGN

There are four overall components to Project FIT school community social marketing and

school staff wellness - all that focus on 1) increasing access to safe and affordable physical

activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)

improving the affordability and availability of nutritious food in the neighborhoods surrounding

the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding

nutrition and physical activity among school staff parents and students 4) impacting the

culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging

dialogue among all community partners to leverage existing programs and introduce new

ones

Mary J

Female

White

56 years old at start of Look AHEAD

study

Past Medical History Type 2 diabetes

overweight diverticulosis arthritis

sleep apnea back pain

Mary J

bullLong term strugglesbull Helping youngest daughter with

personal issues and children

bull Rotator cuff problems

bull Degenerative disks in back

bull Rheumatoid arthritis

bull Diabetes

bull Physically demanding job

bull Financial struggles

Pounds

Years

82007 grandkids enter pre-school

Catherine L

Female

White

47 years old at start of Look AHEAD

study

Past Medical History Type 2 diabetes

overweight high blood pressure

hypothyroidism back pain

Catherine L

Long term struggles

bull Motherrsquos declining health and death

bull Multiple serious injuries

bull Sudden death of sister

bull Death of step-father

bull Declining economy

bull Children living at home

Pounds

Years

Realistic Management Goals

5-10 weight loss

Health energy and fitness

Well-being and self-esteem

Mood and appearance

Functional and recreational

activity

Key Elements

Focus on health and energy

Food and physical activity diaries

Gradual increase in physical activity

Gradual reduction in dietary fat

No feelings of food deprivation

Social support groups

Recommended Strategies for Building

Sustainable Healthy Communities

Overview from USA

Promote the availability of affordable healthy

food and beverages

Support healthy food and beverage choices

Encourage breastfeeding

Encourage physical activity or limit sedentary

activity among children amp youth

Create safe communities that support physical

activity

Encourage communities to organize for change

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Increase the availability of healthier food and

beverage choices in public service venues (eg

schools city amp county buildings etc)

--Insufficient evidence in school-based programs

--Associations suggest availability amp increased

consumption

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve availability of affordable healthier

food amp beverage choices in public service

venues

--Reducing the cost of healthier foods

increases their purchase

--Providing coupons redeemable for

healthier foods increases their purchase

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve geographic availability of

supermarkets in underserved areas

-- Greater access to nearby supermarkets is

associated with healthier eating behaviors

-- Increasing the number of supermarkets in

underserved neighborhoods increased

real estate values increased economic

activity amp employment amp resulted in lower

food prices

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Provide incentives to food retailers to locate in

andor offer healthier food choices in

underserved areas

-- Presence of retail venues that provide healthier

foods is associated with better nutrition

-- Greater availability of supermarkets was

associated with lower adolescent BMI scores

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Improve availability of mechanisms for

purchasing foods from farms

--Evidence supporting a direct link between

purchasing food from farms amp improved diet is

limited

--Two studies of initiatives to encourage

participation in farmersrsquo market showed

increased intention to eat more fruits amp

vegetables but no direct evidence

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Provide incentives for the production

distribution and procurement of foods from local

farms

--No evidence has been published to link local

food production amp health outcomes

--There is a current study exploring the potential

nutritional amp health benefits of eating locally

grown foods

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Restrict availability of less healthy foods amp

beverages in public service venues

--No peer-reviewed studies examined the impact

designed to restrict availability of less healthy

foods in public service venues

--21 states have policies that restrict the sale of

competitive foods in schools beyond USDA

regulations however no studies have evaluated

the impact of the policies

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Institute smaller portion size options in public

service venues

--Evidence is lacking to demonstrate effectiveness

of population-based interventions aimed at

reducing portion sizes in public service venues

--Evidence from clinical studies in laboratories

demonstrates decreasing portion sizes

decreases energy intake

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Limit advertisements of less healthy foods amp

beverages

--Little evidence is available regarding the impact

of restricting advertising on purchasing amp

consumption of less healthy foods

--Cross-sectional time-series studies of tobacco-

control efforts suggest an association between

advertising bans amp decreased tobacco

consumption

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Discourage consumption of sugar-sweetened

beverages

--One longitudinal study of a school-based

intervention among Native-American high school

students showed a substantial reduction in

sugar-sweetened beverages over a 3-year

period

--A RCT of a home-based intervention that

eliminated sugar-sweetened beverages showed

reduction in BMI scores

Recommended Community Strategies Strategies to encourage breastfeeding

Increase support for breastfeeding

--Evidence directly linking environmental

interventions that support breastfeeding with

obesity-related outcomes is lacking

--Epidemiologic studies indicate that breastfeeding

helps prevent pediatric obesity

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Require physical education in schools

--14 studies have demonstrated that school-based

PE was effective in increasing levels of physical

activity and improving physical fitness

--Minimum of 150 minwk in elementary schools

225 minwk in middle schools and high schools

throughout the school year as recommended by

NASPE

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Increase opportunities for extracurricular

physical activity

--Participation in after-school programs increased

studentsrsquo level of physical activity amp improved

obesity-related outcomes (improved CV fitness

reduced body fat)

--2 pilot studies providing extracurricular physical

activity showed increased levels of PA amp

decreased sedentary behavior

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Reduce screen time in public service venues

--A school-based RCT indicated that children who

reduced their television videotape amp video

game use had significant decrease in BMI tricep

skin fold thickness amp waist circumference

compared to controls

--Spending less time watching television is

associated with increased physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Improve access to outdoor recreational

facilities

--Review of 108 studies indicated that access to facilities

and programs for recreation near their homes amp time

spent outdoors correlated positively with increased

physical activity among childrenamp adults

--Perceptions that footpaths are safe for walking was

significantly associated with adults being classified as

physically active at a level sufficient for health benefits

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting

bicycling

--Longitudinal intervention studies have

demonstrated that improving bicycling

infrastructure is associated with increased

frequency of bicycling

--Cross-sectional studies indicated a significant

association between bicycling infrastructure amp

frequency of biking

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting walking

--Reviews of cross-sectional studies of

environmental correlates of physical activity amp

walking generally find a positive association

between infrastructure supportive of walking amp

physical activity

--Identifying amp creating safe routes to school

together with educational components

increased the number of students walking to

school

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Locating schools within easy walking

distance of residential areas

--Community-scale urban design amp land use policies amp

practices including locating schools stores workplaces

amp recreation areas close to residential areas are

effective in facilitating an increase in levels of physical

activity

--Majority of efforts to encourage walking to school involve

improving the routes rather than improving the location

of schools

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Improve access to public transportation

--Insufficient evidence exists to determine

effectiveness of transportation policies in

increasing the level of physical activity or

improving fitness

--1 study indicated that 29 of individuals who

walk to and from public transit achieve at least

30 minutes of daily physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Zone for mixed-use development

--Allows residential commercial institutional amp

other public land uses to be located in close

proximity to one another

--Studies using correlation analyses amp regression

models indicated that mixed land use was

associated with increased walking amp cycling

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance personal safety in areas where

persons are or could be physically active

--Cross-sectional studies have demonstrated a

negative relationship between crime rates andor

perceived safety amp physical activity in

neighborhoods

--Few intervention studies have evaluated the

impact of policies amp practices to improve

personal safety on physical activity

Geospatial Mapping Linking Urban

Environments to Health Risk

Measure association between environmental variables amp health risk factors

Assess relationships between variables at different levels of analysis

Used in conjunction with linear analyses

Our Community Environmental Model

of Obesity

Community Factors

Poverty

Crime

Grocery Quality

Restaurants

Parks

Sidewalks

Fast Food Outlets

Recreational

Facilities

Individual Factors

Dietary Intake

Physical Activity

Genetics

Family History

StressCoping

Eating Disorders

Psychological

Problems

Weight

Status

Chosen Neighborhoods

Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped

We then matched census-block groups within the income groups by population density and percentage of minority representation

One matched block group per income level was randomly selected

Prevalence of Obesity in

Block-Groups

0

5

10

15

20

25

30

35

40

45

50

Ag

e-a

dju

sted

Ob

esit

y P

rev

ale

nce

(

)

High-Income Low-Income

Age-standardized to the 1990 US Census

Density of Environmental Factors in the

Community Contributes to a ldquoToxicrdquo

Obesity Environment

0

2

4

6

8

10

12

14

16

18

Fast-food Convenience Store Bars

Den

sity

10

00

perso

ns

High-Income Low-Income

COMMUNITYrsquoS PERCEPTION OF SAFETY

0

5

10

15

20

25

30

35

40

Daytime Nighttime

Perc

en

t (

) F

eeli

ng

So

mew

hat

Safe

or

Un

safe

Low-Income High-Income

Percent Substandard (or worse) Housing

or Ground Conditions

of Residential Properties

0

10

20

30

Structural Grounds

Perc

en

t (

)

Low-Income High-Income

CONCLUSIONS

These data suggest that the higher

frequency of outlets providing

calorically-dense foods and alcohol may

contribute to greater obesity prevalence

in residents of low-income communities

More research is needed to thoroughly

document environmental determinants

of health and obesity

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

From 1994-1998 HUD randomly assigned

4498 women with children living in public

housing in high-poverty urban census

tracts to one of three groups (1) housing

vouchers redeemable only if they moved

to a low-poverty census tract (2)

unrestricted vouchers or (3) control group

(no vouchers)

Ludwig et al NEJM 201136516

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

10-12 year follow-up showed modest but

potentially important reductions in the

prevalence of extreme obesity amp diabetes in the

group moving from a neighborhood with high

poverty on one of low poverty compared to the

control group

No differences between the group receiving

traditional vouchers amp the control group

ldquoNeighborhoods matterrdquo

Ludwig et al NEJM 201136516

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance traffic safety in areas where

persons are or could be physically active

--Community-scale urban design amp land use policies to

promote physical activity including design components

to improve street lighting infrastructure projects to

increase safety of pedestrian street crossing and use of

traffic calming approaches such as speed humps amp

traffic circles are effective in increasing physical activity

--Both community-scale amp street-scale policies amp practices

are effective in increasing physical activity

Recommended Community Strategies Encourage Communities to Organize for Change

Participate in community coalitions or

partnerships to address obesity

--Little evidence is available to determine the

impact of community coalitions on obesity

prevention

--The presence of anti-smoking community

coalitions has been associated with lower rates

of tobacco consumption

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

$103 million awarded to 61 states and

communities including state amp local government

agencies tribes amp territories amp state amp local non-

profit organizations

To build capacity to implement changes for

community prevention efforts to ensure long-

term success

To implement evidence-based and practice-

based programs to improve health amp wellness

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Priority areas are

Tobacco-free living

Active living and healthy eating

Evidence-based quality clinical and other

preventive health services for prevention

and control of high blood pressure and

high cholesterol

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Applicants proposed specific activities in

line with their chosen priority areas in their

applications

Grantee activities will not be finalized until

plans are negotiated with CDC by early

2012

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Capacity-Building Award

The Confederated Tribes of The Chehalis

Reservation is receiving a $498663 planning

award to build capacity to support healthy

lifestyles among their tribal population of 1500

in Washington State

Work will target tobacco-free living active living

and healthy eating and quality clinical and other

healthy serviceswwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Implementation Award

Austin TX Dept of Health and Human Services

is receiving $1026158 to serve Travis County

(Austin) to expand efforts in tobacco-free living

active living and healthy eating quality clinical

and other preventive services social and

emotional wellness and healthy and safe

physical environmentswwwcdcgov1052011

Building sustainable healthy

communities Bottom line

Obesity is an environmental problem

Despite progress in genetic research public health advances only will occur when we take the environment seriously

Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment

Until we do this we will not make substantial progress in addressing the epidemic of obesity

Poston amp Foreyt Atherosclerosis 1999

Whatrsquos the best approach

Integrate all sectors of society into community

change interventions

Incorporate

Science amp Technology

Education

FamilyCommunity

Healthcare

Arts amp Entertainment

Law amp Politics

Commerce amp Trade

Sectors of Society

Arts amp Entertainm

ent

Commerce amp Trade

Education

FamilyCommunity

Healthcare

Law amp Politics

Science amp Technology

Project FIT rationale design and baseline characteristics of a school- and community-

based intervention to address physical activity and healthy eating among low-income

elementary school children

Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D

Oh HJ Orth J Randall S Mayfield K Holmes D

Source

Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu

Abstract

BACKGROUND

This paper describes Project FIT a collaboration between the public school system local

health systems physicians neighborhood associations businesses faith-based leaders

community agencies and university researchers to develop a multi-faceted approach to

promote physical activity and healthy eating toward the general goal of preventing and

reducing childhood obesity among children in Grand Rapids MI USA

METHODSDESIGN

There are four overall components to Project FIT school community social marketing and

school staff wellness - all that focus on 1) increasing access to safe and affordable physical

activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)

improving the affordability and availability of nutritious food in the neighborhoods surrounding

the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding

nutrition and physical activity among school staff parents and students 4) impacting the

culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging

dialogue among all community partners to leverage existing programs and introduce new

ones

Mary J

bullLong term strugglesbull Helping youngest daughter with

personal issues and children

bull Rotator cuff problems

bull Degenerative disks in back

bull Rheumatoid arthritis

bull Diabetes

bull Physically demanding job

bull Financial struggles

Pounds

Years

82007 grandkids enter pre-school

Catherine L

Female

White

47 years old at start of Look AHEAD

study

Past Medical History Type 2 diabetes

overweight high blood pressure

hypothyroidism back pain

Catherine L

Long term struggles

bull Motherrsquos declining health and death

bull Multiple serious injuries

bull Sudden death of sister

bull Death of step-father

bull Declining economy

bull Children living at home

Pounds

Years

Realistic Management Goals

5-10 weight loss

Health energy and fitness

Well-being and self-esteem

Mood and appearance

Functional and recreational

activity

Key Elements

Focus on health and energy

Food and physical activity diaries

Gradual increase in physical activity

Gradual reduction in dietary fat

No feelings of food deprivation

Social support groups

Recommended Strategies for Building

Sustainable Healthy Communities

Overview from USA

Promote the availability of affordable healthy

food and beverages

Support healthy food and beverage choices

Encourage breastfeeding

Encourage physical activity or limit sedentary

activity among children amp youth

Create safe communities that support physical

activity

Encourage communities to organize for change

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Increase the availability of healthier food and

beverage choices in public service venues (eg

schools city amp county buildings etc)

--Insufficient evidence in school-based programs

--Associations suggest availability amp increased

consumption

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve availability of affordable healthier

food amp beverage choices in public service

venues

--Reducing the cost of healthier foods

increases their purchase

--Providing coupons redeemable for

healthier foods increases their purchase

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve geographic availability of

supermarkets in underserved areas

-- Greater access to nearby supermarkets is

associated with healthier eating behaviors

-- Increasing the number of supermarkets in

underserved neighborhoods increased

real estate values increased economic

activity amp employment amp resulted in lower

food prices

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Provide incentives to food retailers to locate in

andor offer healthier food choices in

underserved areas

-- Presence of retail venues that provide healthier

foods is associated with better nutrition

-- Greater availability of supermarkets was

associated with lower adolescent BMI scores

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Improve availability of mechanisms for

purchasing foods from farms

--Evidence supporting a direct link between

purchasing food from farms amp improved diet is

limited

--Two studies of initiatives to encourage

participation in farmersrsquo market showed

increased intention to eat more fruits amp

vegetables but no direct evidence

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Provide incentives for the production

distribution and procurement of foods from local

farms

--No evidence has been published to link local

food production amp health outcomes

--There is a current study exploring the potential

nutritional amp health benefits of eating locally

grown foods

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Restrict availability of less healthy foods amp

beverages in public service venues

--No peer-reviewed studies examined the impact

designed to restrict availability of less healthy

foods in public service venues

--21 states have policies that restrict the sale of

competitive foods in schools beyond USDA

regulations however no studies have evaluated

the impact of the policies

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Institute smaller portion size options in public

service venues

--Evidence is lacking to demonstrate effectiveness

of population-based interventions aimed at

reducing portion sizes in public service venues

--Evidence from clinical studies in laboratories

demonstrates decreasing portion sizes

decreases energy intake

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Limit advertisements of less healthy foods amp

beverages

--Little evidence is available regarding the impact

of restricting advertising on purchasing amp

consumption of less healthy foods

--Cross-sectional time-series studies of tobacco-

control efforts suggest an association between

advertising bans amp decreased tobacco

consumption

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Discourage consumption of sugar-sweetened

beverages

--One longitudinal study of a school-based

intervention among Native-American high school

students showed a substantial reduction in

sugar-sweetened beverages over a 3-year

period

--A RCT of a home-based intervention that

eliminated sugar-sweetened beverages showed

reduction in BMI scores

Recommended Community Strategies Strategies to encourage breastfeeding

Increase support for breastfeeding

--Evidence directly linking environmental

interventions that support breastfeeding with

obesity-related outcomes is lacking

--Epidemiologic studies indicate that breastfeeding

helps prevent pediatric obesity

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Require physical education in schools

--14 studies have demonstrated that school-based

PE was effective in increasing levels of physical

activity and improving physical fitness

--Minimum of 150 minwk in elementary schools

225 minwk in middle schools and high schools

throughout the school year as recommended by

NASPE

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Increase opportunities for extracurricular

physical activity

--Participation in after-school programs increased

studentsrsquo level of physical activity amp improved

obesity-related outcomes (improved CV fitness

reduced body fat)

--2 pilot studies providing extracurricular physical

activity showed increased levels of PA amp

decreased sedentary behavior

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Reduce screen time in public service venues

--A school-based RCT indicated that children who

reduced their television videotape amp video

game use had significant decrease in BMI tricep

skin fold thickness amp waist circumference

compared to controls

--Spending less time watching television is

associated with increased physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Improve access to outdoor recreational

facilities

--Review of 108 studies indicated that access to facilities

and programs for recreation near their homes amp time

spent outdoors correlated positively with increased

physical activity among childrenamp adults

--Perceptions that footpaths are safe for walking was

significantly associated with adults being classified as

physically active at a level sufficient for health benefits

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting

bicycling

--Longitudinal intervention studies have

demonstrated that improving bicycling

infrastructure is associated with increased

frequency of bicycling

--Cross-sectional studies indicated a significant

association between bicycling infrastructure amp

frequency of biking

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting walking

--Reviews of cross-sectional studies of

environmental correlates of physical activity amp

walking generally find a positive association

between infrastructure supportive of walking amp

physical activity

--Identifying amp creating safe routes to school

together with educational components

increased the number of students walking to

school

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Locating schools within easy walking

distance of residential areas

--Community-scale urban design amp land use policies amp

practices including locating schools stores workplaces

amp recreation areas close to residential areas are

effective in facilitating an increase in levels of physical

activity

--Majority of efforts to encourage walking to school involve

improving the routes rather than improving the location

of schools

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Improve access to public transportation

--Insufficient evidence exists to determine

effectiveness of transportation policies in

increasing the level of physical activity or

improving fitness

--1 study indicated that 29 of individuals who

walk to and from public transit achieve at least

30 minutes of daily physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Zone for mixed-use development

--Allows residential commercial institutional amp

other public land uses to be located in close

proximity to one another

--Studies using correlation analyses amp regression

models indicated that mixed land use was

associated with increased walking amp cycling

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance personal safety in areas where

persons are or could be physically active

--Cross-sectional studies have demonstrated a

negative relationship between crime rates andor

perceived safety amp physical activity in

neighborhoods

--Few intervention studies have evaluated the

impact of policies amp practices to improve

personal safety on physical activity

Geospatial Mapping Linking Urban

Environments to Health Risk

Measure association between environmental variables amp health risk factors

Assess relationships between variables at different levels of analysis

Used in conjunction with linear analyses

Our Community Environmental Model

of Obesity

Community Factors

Poverty

Crime

Grocery Quality

Restaurants

Parks

Sidewalks

Fast Food Outlets

Recreational

Facilities

Individual Factors

Dietary Intake

Physical Activity

Genetics

Family History

StressCoping

Eating Disorders

Psychological

Problems

Weight

Status

Chosen Neighborhoods

Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped

We then matched census-block groups within the income groups by population density and percentage of minority representation

One matched block group per income level was randomly selected

Prevalence of Obesity in

Block-Groups

0

5

10

15

20

25

30

35

40

45

50

Ag

e-a

dju

sted

Ob

esit

y P

rev

ale

nce

(

)

High-Income Low-Income

Age-standardized to the 1990 US Census

Density of Environmental Factors in the

Community Contributes to a ldquoToxicrdquo

Obesity Environment

0

2

4

6

8

10

12

14

16

18

Fast-food Convenience Store Bars

Den

sity

10

00

perso

ns

High-Income Low-Income

COMMUNITYrsquoS PERCEPTION OF SAFETY

0

5

10

15

20

25

30

35

40

Daytime Nighttime

Perc

en

t (

) F

eeli

ng

So

mew

hat

Safe

or

Un

safe

Low-Income High-Income

Percent Substandard (or worse) Housing

or Ground Conditions

of Residential Properties

0

10

20

30

Structural Grounds

Perc

en

t (

)

Low-Income High-Income

CONCLUSIONS

These data suggest that the higher

frequency of outlets providing

calorically-dense foods and alcohol may

contribute to greater obesity prevalence

in residents of low-income communities

More research is needed to thoroughly

document environmental determinants

of health and obesity

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

From 1994-1998 HUD randomly assigned

4498 women with children living in public

housing in high-poverty urban census

tracts to one of three groups (1) housing

vouchers redeemable only if they moved

to a low-poverty census tract (2)

unrestricted vouchers or (3) control group

(no vouchers)

Ludwig et al NEJM 201136516

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

10-12 year follow-up showed modest but

potentially important reductions in the

prevalence of extreme obesity amp diabetes in the

group moving from a neighborhood with high

poverty on one of low poverty compared to the

control group

No differences between the group receiving

traditional vouchers amp the control group

ldquoNeighborhoods matterrdquo

Ludwig et al NEJM 201136516

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance traffic safety in areas where

persons are or could be physically active

--Community-scale urban design amp land use policies to

promote physical activity including design components

to improve street lighting infrastructure projects to

increase safety of pedestrian street crossing and use of

traffic calming approaches such as speed humps amp

traffic circles are effective in increasing physical activity

--Both community-scale amp street-scale policies amp practices

are effective in increasing physical activity

Recommended Community Strategies Encourage Communities to Organize for Change

Participate in community coalitions or

partnerships to address obesity

--Little evidence is available to determine the

impact of community coalitions on obesity

prevention

--The presence of anti-smoking community

coalitions has been associated with lower rates

of tobacco consumption

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

$103 million awarded to 61 states and

communities including state amp local government

agencies tribes amp territories amp state amp local non-

profit organizations

To build capacity to implement changes for

community prevention efforts to ensure long-

term success

To implement evidence-based and practice-

based programs to improve health amp wellness

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Priority areas are

Tobacco-free living

Active living and healthy eating

Evidence-based quality clinical and other

preventive health services for prevention

and control of high blood pressure and

high cholesterol

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Applicants proposed specific activities in

line with their chosen priority areas in their

applications

Grantee activities will not be finalized until

plans are negotiated with CDC by early

2012

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Capacity-Building Award

The Confederated Tribes of The Chehalis

Reservation is receiving a $498663 planning

award to build capacity to support healthy

lifestyles among their tribal population of 1500

in Washington State

Work will target tobacco-free living active living

and healthy eating and quality clinical and other

healthy serviceswwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Implementation Award

Austin TX Dept of Health and Human Services

is receiving $1026158 to serve Travis County

(Austin) to expand efforts in tobacco-free living

active living and healthy eating quality clinical

and other preventive services social and

emotional wellness and healthy and safe

physical environmentswwwcdcgov1052011

Building sustainable healthy

communities Bottom line

Obesity is an environmental problem

Despite progress in genetic research public health advances only will occur when we take the environment seriously

Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment

Until we do this we will not make substantial progress in addressing the epidemic of obesity

Poston amp Foreyt Atherosclerosis 1999

Whatrsquos the best approach

Integrate all sectors of society into community

change interventions

Incorporate

Science amp Technology

Education

FamilyCommunity

Healthcare

Arts amp Entertainment

Law amp Politics

Commerce amp Trade

Sectors of Society

Arts amp Entertainm

ent

Commerce amp Trade

Education

FamilyCommunity

Healthcare

Law amp Politics

Science amp Technology

Project FIT rationale design and baseline characteristics of a school- and community-

based intervention to address physical activity and healthy eating among low-income

elementary school children

Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D

Oh HJ Orth J Randall S Mayfield K Holmes D

Source

Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu

Abstract

BACKGROUND

This paper describes Project FIT a collaboration between the public school system local

health systems physicians neighborhood associations businesses faith-based leaders

community agencies and university researchers to develop a multi-faceted approach to

promote physical activity and healthy eating toward the general goal of preventing and

reducing childhood obesity among children in Grand Rapids MI USA

METHODSDESIGN

There are four overall components to Project FIT school community social marketing and

school staff wellness - all that focus on 1) increasing access to safe and affordable physical

activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)

improving the affordability and availability of nutritious food in the neighborhoods surrounding

the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding

nutrition and physical activity among school staff parents and students 4) impacting the

culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging

dialogue among all community partners to leverage existing programs and introduce new

ones

Pounds

Years

82007 grandkids enter pre-school

Catherine L

Female

White

47 years old at start of Look AHEAD

study

Past Medical History Type 2 diabetes

overweight high blood pressure

hypothyroidism back pain

Catherine L

Long term struggles

bull Motherrsquos declining health and death

bull Multiple serious injuries

bull Sudden death of sister

bull Death of step-father

bull Declining economy

bull Children living at home

Pounds

Years

Realistic Management Goals

5-10 weight loss

Health energy and fitness

Well-being and self-esteem

Mood and appearance

Functional and recreational

activity

Key Elements

Focus on health and energy

Food and physical activity diaries

Gradual increase in physical activity

Gradual reduction in dietary fat

No feelings of food deprivation

Social support groups

Recommended Strategies for Building

Sustainable Healthy Communities

Overview from USA

Promote the availability of affordable healthy

food and beverages

Support healthy food and beverage choices

Encourage breastfeeding

Encourage physical activity or limit sedentary

activity among children amp youth

Create safe communities that support physical

activity

Encourage communities to organize for change

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Increase the availability of healthier food and

beverage choices in public service venues (eg

schools city amp county buildings etc)

--Insufficient evidence in school-based programs

--Associations suggest availability amp increased

consumption

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve availability of affordable healthier

food amp beverage choices in public service

venues

--Reducing the cost of healthier foods

increases their purchase

--Providing coupons redeemable for

healthier foods increases their purchase

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve geographic availability of

supermarkets in underserved areas

-- Greater access to nearby supermarkets is

associated with healthier eating behaviors

-- Increasing the number of supermarkets in

underserved neighborhoods increased

real estate values increased economic

activity amp employment amp resulted in lower

food prices

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Provide incentives to food retailers to locate in

andor offer healthier food choices in

underserved areas

-- Presence of retail venues that provide healthier

foods is associated with better nutrition

-- Greater availability of supermarkets was

associated with lower adolescent BMI scores

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Improve availability of mechanisms for

purchasing foods from farms

--Evidence supporting a direct link between

purchasing food from farms amp improved diet is

limited

--Two studies of initiatives to encourage

participation in farmersrsquo market showed

increased intention to eat more fruits amp

vegetables but no direct evidence

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Provide incentives for the production

distribution and procurement of foods from local

farms

--No evidence has been published to link local

food production amp health outcomes

--There is a current study exploring the potential

nutritional amp health benefits of eating locally

grown foods

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Restrict availability of less healthy foods amp

beverages in public service venues

--No peer-reviewed studies examined the impact

designed to restrict availability of less healthy

foods in public service venues

--21 states have policies that restrict the sale of

competitive foods in schools beyond USDA

regulations however no studies have evaluated

the impact of the policies

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Institute smaller portion size options in public

service venues

--Evidence is lacking to demonstrate effectiveness

of population-based interventions aimed at

reducing portion sizes in public service venues

--Evidence from clinical studies in laboratories

demonstrates decreasing portion sizes

decreases energy intake

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Limit advertisements of less healthy foods amp

beverages

--Little evidence is available regarding the impact

of restricting advertising on purchasing amp

consumption of less healthy foods

--Cross-sectional time-series studies of tobacco-

control efforts suggest an association between

advertising bans amp decreased tobacco

consumption

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Discourage consumption of sugar-sweetened

beverages

--One longitudinal study of a school-based

intervention among Native-American high school

students showed a substantial reduction in

sugar-sweetened beverages over a 3-year

period

--A RCT of a home-based intervention that

eliminated sugar-sweetened beverages showed

reduction in BMI scores

Recommended Community Strategies Strategies to encourage breastfeeding

Increase support for breastfeeding

--Evidence directly linking environmental

interventions that support breastfeeding with

obesity-related outcomes is lacking

--Epidemiologic studies indicate that breastfeeding

helps prevent pediatric obesity

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Require physical education in schools

--14 studies have demonstrated that school-based

PE was effective in increasing levels of physical

activity and improving physical fitness

--Minimum of 150 minwk in elementary schools

225 minwk in middle schools and high schools

throughout the school year as recommended by

NASPE

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Increase opportunities for extracurricular

physical activity

--Participation in after-school programs increased

studentsrsquo level of physical activity amp improved

obesity-related outcomes (improved CV fitness

reduced body fat)

--2 pilot studies providing extracurricular physical

activity showed increased levels of PA amp

decreased sedentary behavior

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Reduce screen time in public service venues

--A school-based RCT indicated that children who

reduced their television videotape amp video

game use had significant decrease in BMI tricep

skin fold thickness amp waist circumference

compared to controls

--Spending less time watching television is

associated with increased physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Improve access to outdoor recreational

facilities

--Review of 108 studies indicated that access to facilities

and programs for recreation near their homes amp time

spent outdoors correlated positively with increased

physical activity among childrenamp adults

--Perceptions that footpaths are safe for walking was

significantly associated with adults being classified as

physically active at a level sufficient for health benefits

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting

bicycling

--Longitudinal intervention studies have

demonstrated that improving bicycling

infrastructure is associated with increased

frequency of bicycling

--Cross-sectional studies indicated a significant

association between bicycling infrastructure amp

frequency of biking

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting walking

--Reviews of cross-sectional studies of

environmental correlates of physical activity amp

walking generally find a positive association

between infrastructure supportive of walking amp

physical activity

--Identifying amp creating safe routes to school

together with educational components

increased the number of students walking to

school

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Locating schools within easy walking

distance of residential areas

--Community-scale urban design amp land use policies amp

practices including locating schools stores workplaces

amp recreation areas close to residential areas are

effective in facilitating an increase in levels of physical

activity

--Majority of efforts to encourage walking to school involve

improving the routes rather than improving the location

of schools

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Improve access to public transportation

--Insufficient evidence exists to determine

effectiveness of transportation policies in

increasing the level of physical activity or

improving fitness

--1 study indicated that 29 of individuals who

walk to and from public transit achieve at least

30 minutes of daily physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Zone for mixed-use development

--Allows residential commercial institutional amp

other public land uses to be located in close

proximity to one another

--Studies using correlation analyses amp regression

models indicated that mixed land use was

associated with increased walking amp cycling

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance personal safety in areas where

persons are or could be physically active

--Cross-sectional studies have demonstrated a

negative relationship between crime rates andor

perceived safety amp physical activity in

neighborhoods

--Few intervention studies have evaluated the

impact of policies amp practices to improve

personal safety on physical activity

Geospatial Mapping Linking Urban

Environments to Health Risk

Measure association between environmental variables amp health risk factors

Assess relationships between variables at different levels of analysis

Used in conjunction with linear analyses

Our Community Environmental Model

of Obesity

Community Factors

Poverty

Crime

Grocery Quality

Restaurants

Parks

Sidewalks

Fast Food Outlets

Recreational

Facilities

Individual Factors

Dietary Intake

Physical Activity

Genetics

Family History

StressCoping

Eating Disorders

Psychological

Problems

Weight

Status

Chosen Neighborhoods

Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped

We then matched census-block groups within the income groups by population density and percentage of minority representation

One matched block group per income level was randomly selected

Prevalence of Obesity in

Block-Groups

0

5

10

15

20

25

30

35

40

45

50

Ag

e-a

dju

sted

Ob

esit

y P

rev

ale

nce

(

)

High-Income Low-Income

Age-standardized to the 1990 US Census

Density of Environmental Factors in the

Community Contributes to a ldquoToxicrdquo

Obesity Environment

0

2

4

6

8

10

12

14

16

18

Fast-food Convenience Store Bars

Den

sity

10

00

perso

ns

High-Income Low-Income

COMMUNITYrsquoS PERCEPTION OF SAFETY

0

5

10

15

20

25

30

35

40

Daytime Nighttime

Perc

en

t (

) F

eeli

ng

So

mew

hat

Safe

or

Un

safe

Low-Income High-Income

Percent Substandard (or worse) Housing

or Ground Conditions

of Residential Properties

0

10

20

30

Structural Grounds

Perc

en

t (

)

Low-Income High-Income

CONCLUSIONS

These data suggest that the higher

frequency of outlets providing

calorically-dense foods and alcohol may

contribute to greater obesity prevalence

in residents of low-income communities

More research is needed to thoroughly

document environmental determinants

of health and obesity

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

From 1994-1998 HUD randomly assigned

4498 women with children living in public

housing in high-poverty urban census

tracts to one of three groups (1) housing

vouchers redeemable only if they moved

to a low-poverty census tract (2)

unrestricted vouchers or (3) control group

(no vouchers)

Ludwig et al NEJM 201136516

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

10-12 year follow-up showed modest but

potentially important reductions in the

prevalence of extreme obesity amp diabetes in the

group moving from a neighborhood with high

poverty on one of low poverty compared to the

control group

No differences between the group receiving

traditional vouchers amp the control group

ldquoNeighborhoods matterrdquo

Ludwig et al NEJM 201136516

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance traffic safety in areas where

persons are or could be physically active

--Community-scale urban design amp land use policies to

promote physical activity including design components

to improve street lighting infrastructure projects to

increase safety of pedestrian street crossing and use of

traffic calming approaches such as speed humps amp

traffic circles are effective in increasing physical activity

--Both community-scale amp street-scale policies amp practices

are effective in increasing physical activity

Recommended Community Strategies Encourage Communities to Organize for Change

Participate in community coalitions or

partnerships to address obesity

--Little evidence is available to determine the

impact of community coalitions on obesity

prevention

--The presence of anti-smoking community

coalitions has been associated with lower rates

of tobacco consumption

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

$103 million awarded to 61 states and

communities including state amp local government

agencies tribes amp territories amp state amp local non-

profit organizations

To build capacity to implement changes for

community prevention efforts to ensure long-

term success

To implement evidence-based and practice-

based programs to improve health amp wellness

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Priority areas are

Tobacco-free living

Active living and healthy eating

Evidence-based quality clinical and other

preventive health services for prevention

and control of high blood pressure and

high cholesterol

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Applicants proposed specific activities in

line with their chosen priority areas in their

applications

Grantee activities will not be finalized until

plans are negotiated with CDC by early

2012

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Capacity-Building Award

The Confederated Tribes of The Chehalis

Reservation is receiving a $498663 planning

award to build capacity to support healthy

lifestyles among their tribal population of 1500

in Washington State

Work will target tobacco-free living active living

and healthy eating and quality clinical and other

healthy serviceswwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Implementation Award

Austin TX Dept of Health and Human Services

is receiving $1026158 to serve Travis County

(Austin) to expand efforts in tobacco-free living

active living and healthy eating quality clinical

and other preventive services social and

emotional wellness and healthy and safe

physical environmentswwwcdcgov1052011

Building sustainable healthy

communities Bottom line

Obesity is an environmental problem

Despite progress in genetic research public health advances only will occur when we take the environment seriously

Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment

Until we do this we will not make substantial progress in addressing the epidemic of obesity

Poston amp Foreyt Atherosclerosis 1999

Whatrsquos the best approach

Integrate all sectors of society into community

change interventions

Incorporate

Science amp Technology

Education

FamilyCommunity

Healthcare

Arts amp Entertainment

Law amp Politics

Commerce amp Trade

Sectors of Society

Arts amp Entertainm

ent

Commerce amp Trade

Education

FamilyCommunity

Healthcare

Law amp Politics

Science amp Technology

Project FIT rationale design and baseline characteristics of a school- and community-

based intervention to address physical activity and healthy eating among low-income

elementary school children

Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D

Oh HJ Orth J Randall S Mayfield K Holmes D

Source

Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu

Abstract

BACKGROUND

This paper describes Project FIT a collaboration between the public school system local

health systems physicians neighborhood associations businesses faith-based leaders

community agencies and university researchers to develop a multi-faceted approach to

promote physical activity and healthy eating toward the general goal of preventing and

reducing childhood obesity among children in Grand Rapids MI USA

METHODSDESIGN

There are four overall components to Project FIT school community social marketing and

school staff wellness - all that focus on 1) increasing access to safe and affordable physical

activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)

improving the affordability and availability of nutritious food in the neighborhoods surrounding

the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding

nutrition and physical activity among school staff parents and students 4) impacting the

culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging

dialogue among all community partners to leverage existing programs and introduce new

ones

Catherine L

Female

White

47 years old at start of Look AHEAD

study

Past Medical History Type 2 diabetes

overweight high blood pressure

hypothyroidism back pain

Catherine L

Long term struggles

bull Motherrsquos declining health and death

bull Multiple serious injuries

bull Sudden death of sister

bull Death of step-father

bull Declining economy

bull Children living at home

Pounds

Years

Realistic Management Goals

5-10 weight loss

Health energy and fitness

Well-being and self-esteem

Mood and appearance

Functional and recreational

activity

Key Elements

Focus on health and energy

Food and physical activity diaries

Gradual increase in physical activity

Gradual reduction in dietary fat

No feelings of food deprivation

Social support groups

Recommended Strategies for Building

Sustainable Healthy Communities

Overview from USA

Promote the availability of affordable healthy

food and beverages

Support healthy food and beverage choices

Encourage breastfeeding

Encourage physical activity or limit sedentary

activity among children amp youth

Create safe communities that support physical

activity

Encourage communities to organize for change

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Increase the availability of healthier food and

beverage choices in public service venues (eg

schools city amp county buildings etc)

--Insufficient evidence in school-based programs

--Associations suggest availability amp increased

consumption

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve availability of affordable healthier

food amp beverage choices in public service

venues

--Reducing the cost of healthier foods

increases their purchase

--Providing coupons redeemable for

healthier foods increases their purchase

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve geographic availability of

supermarkets in underserved areas

-- Greater access to nearby supermarkets is

associated with healthier eating behaviors

-- Increasing the number of supermarkets in

underserved neighborhoods increased

real estate values increased economic

activity amp employment amp resulted in lower

food prices

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Provide incentives to food retailers to locate in

andor offer healthier food choices in

underserved areas

-- Presence of retail venues that provide healthier

foods is associated with better nutrition

-- Greater availability of supermarkets was

associated with lower adolescent BMI scores

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Improve availability of mechanisms for

purchasing foods from farms

--Evidence supporting a direct link between

purchasing food from farms amp improved diet is

limited

--Two studies of initiatives to encourage

participation in farmersrsquo market showed

increased intention to eat more fruits amp

vegetables but no direct evidence

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Provide incentives for the production

distribution and procurement of foods from local

farms

--No evidence has been published to link local

food production amp health outcomes

--There is a current study exploring the potential

nutritional amp health benefits of eating locally

grown foods

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Restrict availability of less healthy foods amp

beverages in public service venues

--No peer-reviewed studies examined the impact

designed to restrict availability of less healthy

foods in public service venues

--21 states have policies that restrict the sale of

competitive foods in schools beyond USDA

regulations however no studies have evaluated

the impact of the policies

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Institute smaller portion size options in public

service venues

--Evidence is lacking to demonstrate effectiveness

of population-based interventions aimed at

reducing portion sizes in public service venues

--Evidence from clinical studies in laboratories

demonstrates decreasing portion sizes

decreases energy intake

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Limit advertisements of less healthy foods amp

beverages

--Little evidence is available regarding the impact

of restricting advertising on purchasing amp

consumption of less healthy foods

--Cross-sectional time-series studies of tobacco-

control efforts suggest an association between

advertising bans amp decreased tobacco

consumption

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Discourage consumption of sugar-sweetened

beverages

--One longitudinal study of a school-based

intervention among Native-American high school

students showed a substantial reduction in

sugar-sweetened beverages over a 3-year

period

--A RCT of a home-based intervention that

eliminated sugar-sweetened beverages showed

reduction in BMI scores

Recommended Community Strategies Strategies to encourage breastfeeding

Increase support for breastfeeding

--Evidence directly linking environmental

interventions that support breastfeeding with

obesity-related outcomes is lacking

--Epidemiologic studies indicate that breastfeeding

helps prevent pediatric obesity

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Require physical education in schools

--14 studies have demonstrated that school-based

PE was effective in increasing levels of physical

activity and improving physical fitness

--Minimum of 150 minwk in elementary schools

225 minwk in middle schools and high schools

throughout the school year as recommended by

NASPE

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Increase opportunities for extracurricular

physical activity

--Participation in after-school programs increased

studentsrsquo level of physical activity amp improved

obesity-related outcomes (improved CV fitness

reduced body fat)

--2 pilot studies providing extracurricular physical

activity showed increased levels of PA amp

decreased sedentary behavior

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Reduce screen time in public service venues

--A school-based RCT indicated that children who

reduced their television videotape amp video

game use had significant decrease in BMI tricep

skin fold thickness amp waist circumference

compared to controls

--Spending less time watching television is

associated with increased physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Improve access to outdoor recreational

facilities

--Review of 108 studies indicated that access to facilities

and programs for recreation near their homes amp time

spent outdoors correlated positively with increased

physical activity among childrenamp adults

--Perceptions that footpaths are safe for walking was

significantly associated with adults being classified as

physically active at a level sufficient for health benefits

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting

bicycling

--Longitudinal intervention studies have

demonstrated that improving bicycling

infrastructure is associated with increased

frequency of bicycling

--Cross-sectional studies indicated a significant

association between bicycling infrastructure amp

frequency of biking

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting walking

--Reviews of cross-sectional studies of

environmental correlates of physical activity amp

walking generally find a positive association

between infrastructure supportive of walking amp

physical activity

--Identifying amp creating safe routes to school

together with educational components

increased the number of students walking to

school

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Locating schools within easy walking

distance of residential areas

--Community-scale urban design amp land use policies amp

practices including locating schools stores workplaces

amp recreation areas close to residential areas are

effective in facilitating an increase in levels of physical

activity

--Majority of efforts to encourage walking to school involve

improving the routes rather than improving the location

of schools

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Improve access to public transportation

--Insufficient evidence exists to determine

effectiveness of transportation policies in

increasing the level of physical activity or

improving fitness

--1 study indicated that 29 of individuals who

walk to and from public transit achieve at least

30 minutes of daily physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Zone for mixed-use development

--Allows residential commercial institutional amp

other public land uses to be located in close

proximity to one another

--Studies using correlation analyses amp regression

models indicated that mixed land use was

associated with increased walking amp cycling

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance personal safety in areas where

persons are or could be physically active

--Cross-sectional studies have demonstrated a

negative relationship between crime rates andor

perceived safety amp physical activity in

neighborhoods

--Few intervention studies have evaluated the

impact of policies amp practices to improve

personal safety on physical activity

Geospatial Mapping Linking Urban

Environments to Health Risk

Measure association between environmental variables amp health risk factors

Assess relationships between variables at different levels of analysis

Used in conjunction with linear analyses

Our Community Environmental Model

of Obesity

Community Factors

Poverty

Crime

Grocery Quality

Restaurants

Parks

Sidewalks

Fast Food Outlets

Recreational

Facilities

Individual Factors

Dietary Intake

Physical Activity

Genetics

Family History

StressCoping

Eating Disorders

Psychological

Problems

Weight

Status

Chosen Neighborhoods

Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped

We then matched census-block groups within the income groups by population density and percentage of minority representation

One matched block group per income level was randomly selected

Prevalence of Obesity in

Block-Groups

0

5

10

15

20

25

30

35

40

45

50

Ag

e-a

dju

sted

Ob

esit

y P

rev

ale

nce

(

)

High-Income Low-Income

Age-standardized to the 1990 US Census

Density of Environmental Factors in the

Community Contributes to a ldquoToxicrdquo

Obesity Environment

0

2

4

6

8

10

12

14

16

18

Fast-food Convenience Store Bars

Den

sity

10

00

perso

ns

High-Income Low-Income

COMMUNITYrsquoS PERCEPTION OF SAFETY

0

5

10

15

20

25

30

35

40

Daytime Nighttime

Perc

en

t (

) F

eeli

ng

So

mew

hat

Safe

or

Un

safe

Low-Income High-Income

Percent Substandard (or worse) Housing

or Ground Conditions

of Residential Properties

0

10

20

30

Structural Grounds

Perc

en

t (

)

Low-Income High-Income

CONCLUSIONS

These data suggest that the higher

frequency of outlets providing

calorically-dense foods and alcohol may

contribute to greater obesity prevalence

in residents of low-income communities

More research is needed to thoroughly

document environmental determinants

of health and obesity

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

From 1994-1998 HUD randomly assigned

4498 women with children living in public

housing in high-poverty urban census

tracts to one of three groups (1) housing

vouchers redeemable only if they moved

to a low-poverty census tract (2)

unrestricted vouchers or (3) control group

(no vouchers)

Ludwig et al NEJM 201136516

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

10-12 year follow-up showed modest but

potentially important reductions in the

prevalence of extreme obesity amp diabetes in the

group moving from a neighborhood with high

poverty on one of low poverty compared to the

control group

No differences between the group receiving

traditional vouchers amp the control group

ldquoNeighborhoods matterrdquo

Ludwig et al NEJM 201136516

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance traffic safety in areas where

persons are or could be physically active

--Community-scale urban design amp land use policies to

promote physical activity including design components

to improve street lighting infrastructure projects to

increase safety of pedestrian street crossing and use of

traffic calming approaches such as speed humps amp

traffic circles are effective in increasing physical activity

--Both community-scale amp street-scale policies amp practices

are effective in increasing physical activity

Recommended Community Strategies Encourage Communities to Organize for Change

Participate in community coalitions or

partnerships to address obesity

--Little evidence is available to determine the

impact of community coalitions on obesity

prevention

--The presence of anti-smoking community

coalitions has been associated with lower rates

of tobacco consumption

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

$103 million awarded to 61 states and

communities including state amp local government

agencies tribes amp territories amp state amp local non-

profit organizations

To build capacity to implement changes for

community prevention efforts to ensure long-

term success

To implement evidence-based and practice-

based programs to improve health amp wellness

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Priority areas are

Tobacco-free living

Active living and healthy eating

Evidence-based quality clinical and other

preventive health services for prevention

and control of high blood pressure and

high cholesterol

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Applicants proposed specific activities in

line with their chosen priority areas in their

applications

Grantee activities will not be finalized until

plans are negotiated with CDC by early

2012

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Capacity-Building Award

The Confederated Tribes of The Chehalis

Reservation is receiving a $498663 planning

award to build capacity to support healthy

lifestyles among their tribal population of 1500

in Washington State

Work will target tobacco-free living active living

and healthy eating and quality clinical and other

healthy serviceswwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Implementation Award

Austin TX Dept of Health and Human Services

is receiving $1026158 to serve Travis County

(Austin) to expand efforts in tobacco-free living

active living and healthy eating quality clinical

and other preventive services social and

emotional wellness and healthy and safe

physical environmentswwwcdcgov1052011

Building sustainable healthy

communities Bottom line

Obesity is an environmental problem

Despite progress in genetic research public health advances only will occur when we take the environment seriously

Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment

Until we do this we will not make substantial progress in addressing the epidemic of obesity

Poston amp Foreyt Atherosclerosis 1999

Whatrsquos the best approach

Integrate all sectors of society into community

change interventions

Incorporate

Science amp Technology

Education

FamilyCommunity

Healthcare

Arts amp Entertainment

Law amp Politics

Commerce amp Trade

Sectors of Society

Arts amp Entertainm

ent

Commerce amp Trade

Education

FamilyCommunity

Healthcare

Law amp Politics

Science amp Technology

Project FIT rationale design and baseline characteristics of a school- and community-

based intervention to address physical activity and healthy eating among low-income

elementary school children

Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D

Oh HJ Orth J Randall S Mayfield K Holmes D

Source

Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu

Abstract

BACKGROUND

This paper describes Project FIT a collaboration between the public school system local

health systems physicians neighborhood associations businesses faith-based leaders

community agencies and university researchers to develop a multi-faceted approach to

promote physical activity and healthy eating toward the general goal of preventing and

reducing childhood obesity among children in Grand Rapids MI USA

METHODSDESIGN

There are four overall components to Project FIT school community social marketing and

school staff wellness - all that focus on 1) increasing access to safe and affordable physical

activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)

improving the affordability and availability of nutritious food in the neighborhoods surrounding

the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding

nutrition and physical activity among school staff parents and students 4) impacting the

culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging

dialogue among all community partners to leverage existing programs and introduce new

ones

Catherine L

Long term struggles

bull Motherrsquos declining health and death

bull Multiple serious injuries

bull Sudden death of sister

bull Death of step-father

bull Declining economy

bull Children living at home

Pounds

Years

Realistic Management Goals

5-10 weight loss

Health energy and fitness

Well-being and self-esteem

Mood and appearance

Functional and recreational

activity

Key Elements

Focus on health and energy

Food and physical activity diaries

Gradual increase in physical activity

Gradual reduction in dietary fat

No feelings of food deprivation

Social support groups

Recommended Strategies for Building

Sustainable Healthy Communities

Overview from USA

Promote the availability of affordable healthy

food and beverages

Support healthy food and beverage choices

Encourage breastfeeding

Encourage physical activity or limit sedentary

activity among children amp youth

Create safe communities that support physical

activity

Encourage communities to organize for change

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Increase the availability of healthier food and

beverage choices in public service venues (eg

schools city amp county buildings etc)

--Insufficient evidence in school-based programs

--Associations suggest availability amp increased

consumption

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve availability of affordable healthier

food amp beverage choices in public service

venues

--Reducing the cost of healthier foods

increases their purchase

--Providing coupons redeemable for

healthier foods increases their purchase

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve geographic availability of

supermarkets in underserved areas

-- Greater access to nearby supermarkets is

associated with healthier eating behaviors

-- Increasing the number of supermarkets in

underserved neighborhoods increased

real estate values increased economic

activity amp employment amp resulted in lower

food prices

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Provide incentives to food retailers to locate in

andor offer healthier food choices in

underserved areas

-- Presence of retail venues that provide healthier

foods is associated with better nutrition

-- Greater availability of supermarkets was

associated with lower adolescent BMI scores

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Improve availability of mechanisms for

purchasing foods from farms

--Evidence supporting a direct link between

purchasing food from farms amp improved diet is

limited

--Two studies of initiatives to encourage

participation in farmersrsquo market showed

increased intention to eat more fruits amp

vegetables but no direct evidence

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Provide incentives for the production

distribution and procurement of foods from local

farms

--No evidence has been published to link local

food production amp health outcomes

--There is a current study exploring the potential

nutritional amp health benefits of eating locally

grown foods

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Restrict availability of less healthy foods amp

beverages in public service venues

--No peer-reviewed studies examined the impact

designed to restrict availability of less healthy

foods in public service venues

--21 states have policies that restrict the sale of

competitive foods in schools beyond USDA

regulations however no studies have evaluated

the impact of the policies

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Institute smaller portion size options in public

service venues

--Evidence is lacking to demonstrate effectiveness

of population-based interventions aimed at

reducing portion sizes in public service venues

--Evidence from clinical studies in laboratories

demonstrates decreasing portion sizes

decreases energy intake

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Limit advertisements of less healthy foods amp

beverages

--Little evidence is available regarding the impact

of restricting advertising on purchasing amp

consumption of less healthy foods

--Cross-sectional time-series studies of tobacco-

control efforts suggest an association between

advertising bans amp decreased tobacco

consumption

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Discourage consumption of sugar-sweetened

beverages

--One longitudinal study of a school-based

intervention among Native-American high school

students showed a substantial reduction in

sugar-sweetened beverages over a 3-year

period

--A RCT of a home-based intervention that

eliminated sugar-sweetened beverages showed

reduction in BMI scores

Recommended Community Strategies Strategies to encourage breastfeeding

Increase support for breastfeeding

--Evidence directly linking environmental

interventions that support breastfeeding with

obesity-related outcomes is lacking

--Epidemiologic studies indicate that breastfeeding

helps prevent pediatric obesity

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Require physical education in schools

--14 studies have demonstrated that school-based

PE was effective in increasing levels of physical

activity and improving physical fitness

--Minimum of 150 minwk in elementary schools

225 minwk in middle schools and high schools

throughout the school year as recommended by

NASPE

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Increase opportunities for extracurricular

physical activity

--Participation in after-school programs increased

studentsrsquo level of physical activity amp improved

obesity-related outcomes (improved CV fitness

reduced body fat)

--2 pilot studies providing extracurricular physical

activity showed increased levels of PA amp

decreased sedentary behavior

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Reduce screen time in public service venues

--A school-based RCT indicated that children who

reduced their television videotape amp video

game use had significant decrease in BMI tricep

skin fold thickness amp waist circumference

compared to controls

--Spending less time watching television is

associated with increased physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Improve access to outdoor recreational

facilities

--Review of 108 studies indicated that access to facilities

and programs for recreation near their homes amp time

spent outdoors correlated positively with increased

physical activity among childrenamp adults

--Perceptions that footpaths are safe for walking was

significantly associated with adults being classified as

physically active at a level sufficient for health benefits

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting

bicycling

--Longitudinal intervention studies have

demonstrated that improving bicycling

infrastructure is associated with increased

frequency of bicycling

--Cross-sectional studies indicated a significant

association between bicycling infrastructure amp

frequency of biking

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting walking

--Reviews of cross-sectional studies of

environmental correlates of physical activity amp

walking generally find a positive association

between infrastructure supportive of walking amp

physical activity

--Identifying amp creating safe routes to school

together with educational components

increased the number of students walking to

school

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Locating schools within easy walking

distance of residential areas

--Community-scale urban design amp land use policies amp

practices including locating schools stores workplaces

amp recreation areas close to residential areas are

effective in facilitating an increase in levels of physical

activity

--Majority of efforts to encourage walking to school involve

improving the routes rather than improving the location

of schools

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Improve access to public transportation

--Insufficient evidence exists to determine

effectiveness of transportation policies in

increasing the level of physical activity or

improving fitness

--1 study indicated that 29 of individuals who

walk to and from public transit achieve at least

30 minutes of daily physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Zone for mixed-use development

--Allows residential commercial institutional amp

other public land uses to be located in close

proximity to one another

--Studies using correlation analyses amp regression

models indicated that mixed land use was

associated with increased walking amp cycling

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance personal safety in areas where

persons are or could be physically active

--Cross-sectional studies have demonstrated a

negative relationship between crime rates andor

perceived safety amp physical activity in

neighborhoods

--Few intervention studies have evaluated the

impact of policies amp practices to improve

personal safety on physical activity

Geospatial Mapping Linking Urban

Environments to Health Risk

Measure association between environmental variables amp health risk factors

Assess relationships between variables at different levels of analysis

Used in conjunction with linear analyses

Our Community Environmental Model

of Obesity

Community Factors

Poverty

Crime

Grocery Quality

Restaurants

Parks

Sidewalks

Fast Food Outlets

Recreational

Facilities

Individual Factors

Dietary Intake

Physical Activity

Genetics

Family History

StressCoping

Eating Disorders

Psychological

Problems

Weight

Status

Chosen Neighborhoods

Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped

We then matched census-block groups within the income groups by population density and percentage of minority representation

One matched block group per income level was randomly selected

Prevalence of Obesity in

Block-Groups

0

5

10

15

20

25

30

35

40

45

50

Ag

e-a

dju

sted

Ob

esit

y P

rev

ale

nce

(

)

High-Income Low-Income

Age-standardized to the 1990 US Census

Density of Environmental Factors in the

Community Contributes to a ldquoToxicrdquo

Obesity Environment

0

2

4

6

8

10

12

14

16

18

Fast-food Convenience Store Bars

Den

sity

10

00

perso

ns

High-Income Low-Income

COMMUNITYrsquoS PERCEPTION OF SAFETY

0

5

10

15

20

25

30

35

40

Daytime Nighttime

Perc

en

t (

) F

eeli

ng

So

mew

hat

Safe

or

Un

safe

Low-Income High-Income

Percent Substandard (or worse) Housing

or Ground Conditions

of Residential Properties

0

10

20

30

Structural Grounds

Perc

en

t (

)

Low-Income High-Income

CONCLUSIONS

These data suggest that the higher

frequency of outlets providing

calorically-dense foods and alcohol may

contribute to greater obesity prevalence

in residents of low-income communities

More research is needed to thoroughly

document environmental determinants

of health and obesity

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

From 1994-1998 HUD randomly assigned

4498 women with children living in public

housing in high-poverty urban census

tracts to one of three groups (1) housing

vouchers redeemable only if they moved

to a low-poverty census tract (2)

unrestricted vouchers or (3) control group

(no vouchers)

Ludwig et al NEJM 201136516

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

10-12 year follow-up showed modest but

potentially important reductions in the

prevalence of extreme obesity amp diabetes in the

group moving from a neighborhood with high

poverty on one of low poverty compared to the

control group

No differences between the group receiving

traditional vouchers amp the control group

ldquoNeighborhoods matterrdquo

Ludwig et al NEJM 201136516

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance traffic safety in areas where

persons are or could be physically active

--Community-scale urban design amp land use policies to

promote physical activity including design components

to improve street lighting infrastructure projects to

increase safety of pedestrian street crossing and use of

traffic calming approaches such as speed humps amp

traffic circles are effective in increasing physical activity

--Both community-scale amp street-scale policies amp practices

are effective in increasing physical activity

Recommended Community Strategies Encourage Communities to Organize for Change

Participate in community coalitions or

partnerships to address obesity

--Little evidence is available to determine the

impact of community coalitions on obesity

prevention

--The presence of anti-smoking community

coalitions has been associated with lower rates

of tobacco consumption

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

$103 million awarded to 61 states and

communities including state amp local government

agencies tribes amp territories amp state amp local non-

profit organizations

To build capacity to implement changes for

community prevention efforts to ensure long-

term success

To implement evidence-based and practice-

based programs to improve health amp wellness

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Priority areas are

Tobacco-free living

Active living and healthy eating

Evidence-based quality clinical and other

preventive health services for prevention

and control of high blood pressure and

high cholesterol

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Applicants proposed specific activities in

line with their chosen priority areas in their

applications

Grantee activities will not be finalized until

plans are negotiated with CDC by early

2012

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Capacity-Building Award

The Confederated Tribes of The Chehalis

Reservation is receiving a $498663 planning

award to build capacity to support healthy

lifestyles among their tribal population of 1500

in Washington State

Work will target tobacco-free living active living

and healthy eating and quality clinical and other

healthy serviceswwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Implementation Award

Austin TX Dept of Health and Human Services

is receiving $1026158 to serve Travis County

(Austin) to expand efforts in tobacco-free living

active living and healthy eating quality clinical

and other preventive services social and

emotional wellness and healthy and safe

physical environmentswwwcdcgov1052011

Building sustainable healthy

communities Bottom line

Obesity is an environmental problem

Despite progress in genetic research public health advances only will occur when we take the environment seriously

Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment

Until we do this we will not make substantial progress in addressing the epidemic of obesity

Poston amp Foreyt Atherosclerosis 1999

Whatrsquos the best approach

Integrate all sectors of society into community

change interventions

Incorporate

Science amp Technology

Education

FamilyCommunity

Healthcare

Arts amp Entertainment

Law amp Politics

Commerce amp Trade

Sectors of Society

Arts amp Entertainm

ent

Commerce amp Trade

Education

FamilyCommunity

Healthcare

Law amp Politics

Science amp Technology

Project FIT rationale design and baseline characteristics of a school- and community-

based intervention to address physical activity and healthy eating among low-income

elementary school children

Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D

Oh HJ Orth J Randall S Mayfield K Holmes D

Source

Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu

Abstract

BACKGROUND

This paper describes Project FIT a collaboration between the public school system local

health systems physicians neighborhood associations businesses faith-based leaders

community agencies and university researchers to develop a multi-faceted approach to

promote physical activity and healthy eating toward the general goal of preventing and

reducing childhood obesity among children in Grand Rapids MI USA

METHODSDESIGN

There are four overall components to Project FIT school community social marketing and

school staff wellness - all that focus on 1) increasing access to safe and affordable physical

activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)

improving the affordability and availability of nutritious food in the neighborhoods surrounding

the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding

nutrition and physical activity among school staff parents and students 4) impacting the

culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging

dialogue among all community partners to leverage existing programs and introduce new

ones

Pounds

Years

Realistic Management Goals

5-10 weight loss

Health energy and fitness

Well-being and self-esteem

Mood and appearance

Functional and recreational

activity

Key Elements

Focus on health and energy

Food and physical activity diaries

Gradual increase in physical activity

Gradual reduction in dietary fat

No feelings of food deprivation

Social support groups

Recommended Strategies for Building

Sustainable Healthy Communities

Overview from USA

Promote the availability of affordable healthy

food and beverages

Support healthy food and beverage choices

Encourage breastfeeding

Encourage physical activity or limit sedentary

activity among children amp youth

Create safe communities that support physical

activity

Encourage communities to organize for change

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Increase the availability of healthier food and

beverage choices in public service venues (eg

schools city amp county buildings etc)

--Insufficient evidence in school-based programs

--Associations suggest availability amp increased

consumption

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve availability of affordable healthier

food amp beverage choices in public service

venues

--Reducing the cost of healthier foods

increases their purchase

--Providing coupons redeemable for

healthier foods increases their purchase

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve geographic availability of

supermarkets in underserved areas

-- Greater access to nearby supermarkets is

associated with healthier eating behaviors

-- Increasing the number of supermarkets in

underserved neighborhoods increased

real estate values increased economic

activity amp employment amp resulted in lower

food prices

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Provide incentives to food retailers to locate in

andor offer healthier food choices in

underserved areas

-- Presence of retail venues that provide healthier

foods is associated with better nutrition

-- Greater availability of supermarkets was

associated with lower adolescent BMI scores

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Improve availability of mechanisms for

purchasing foods from farms

--Evidence supporting a direct link between

purchasing food from farms amp improved diet is

limited

--Two studies of initiatives to encourage

participation in farmersrsquo market showed

increased intention to eat more fruits amp

vegetables but no direct evidence

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Provide incentives for the production

distribution and procurement of foods from local

farms

--No evidence has been published to link local

food production amp health outcomes

--There is a current study exploring the potential

nutritional amp health benefits of eating locally

grown foods

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Restrict availability of less healthy foods amp

beverages in public service venues

--No peer-reviewed studies examined the impact

designed to restrict availability of less healthy

foods in public service venues

--21 states have policies that restrict the sale of

competitive foods in schools beyond USDA

regulations however no studies have evaluated

the impact of the policies

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Institute smaller portion size options in public

service venues

--Evidence is lacking to demonstrate effectiveness

of population-based interventions aimed at

reducing portion sizes in public service venues

--Evidence from clinical studies in laboratories

demonstrates decreasing portion sizes

decreases energy intake

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Limit advertisements of less healthy foods amp

beverages

--Little evidence is available regarding the impact

of restricting advertising on purchasing amp

consumption of less healthy foods

--Cross-sectional time-series studies of tobacco-

control efforts suggest an association between

advertising bans amp decreased tobacco

consumption

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Discourage consumption of sugar-sweetened

beverages

--One longitudinal study of a school-based

intervention among Native-American high school

students showed a substantial reduction in

sugar-sweetened beverages over a 3-year

period

--A RCT of a home-based intervention that

eliminated sugar-sweetened beverages showed

reduction in BMI scores

Recommended Community Strategies Strategies to encourage breastfeeding

Increase support for breastfeeding

--Evidence directly linking environmental

interventions that support breastfeeding with

obesity-related outcomes is lacking

--Epidemiologic studies indicate that breastfeeding

helps prevent pediatric obesity

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Require physical education in schools

--14 studies have demonstrated that school-based

PE was effective in increasing levels of physical

activity and improving physical fitness

--Minimum of 150 minwk in elementary schools

225 minwk in middle schools and high schools

throughout the school year as recommended by

NASPE

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Increase opportunities for extracurricular

physical activity

--Participation in after-school programs increased

studentsrsquo level of physical activity amp improved

obesity-related outcomes (improved CV fitness

reduced body fat)

--2 pilot studies providing extracurricular physical

activity showed increased levels of PA amp

decreased sedentary behavior

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Reduce screen time in public service venues

--A school-based RCT indicated that children who

reduced their television videotape amp video

game use had significant decrease in BMI tricep

skin fold thickness amp waist circumference

compared to controls

--Spending less time watching television is

associated with increased physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Improve access to outdoor recreational

facilities

--Review of 108 studies indicated that access to facilities

and programs for recreation near their homes amp time

spent outdoors correlated positively with increased

physical activity among childrenamp adults

--Perceptions that footpaths are safe for walking was

significantly associated with adults being classified as

physically active at a level sufficient for health benefits

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting

bicycling

--Longitudinal intervention studies have

demonstrated that improving bicycling

infrastructure is associated with increased

frequency of bicycling

--Cross-sectional studies indicated a significant

association between bicycling infrastructure amp

frequency of biking

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting walking

--Reviews of cross-sectional studies of

environmental correlates of physical activity amp

walking generally find a positive association

between infrastructure supportive of walking amp

physical activity

--Identifying amp creating safe routes to school

together with educational components

increased the number of students walking to

school

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Locating schools within easy walking

distance of residential areas

--Community-scale urban design amp land use policies amp

practices including locating schools stores workplaces

amp recreation areas close to residential areas are

effective in facilitating an increase in levels of physical

activity

--Majority of efforts to encourage walking to school involve

improving the routes rather than improving the location

of schools

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Improve access to public transportation

--Insufficient evidence exists to determine

effectiveness of transportation policies in

increasing the level of physical activity or

improving fitness

--1 study indicated that 29 of individuals who

walk to and from public transit achieve at least

30 minutes of daily physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Zone for mixed-use development

--Allows residential commercial institutional amp

other public land uses to be located in close

proximity to one another

--Studies using correlation analyses amp regression

models indicated that mixed land use was

associated with increased walking amp cycling

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance personal safety in areas where

persons are or could be physically active

--Cross-sectional studies have demonstrated a

negative relationship between crime rates andor

perceived safety amp physical activity in

neighborhoods

--Few intervention studies have evaluated the

impact of policies amp practices to improve

personal safety on physical activity

Geospatial Mapping Linking Urban

Environments to Health Risk

Measure association between environmental variables amp health risk factors

Assess relationships between variables at different levels of analysis

Used in conjunction with linear analyses

Our Community Environmental Model

of Obesity

Community Factors

Poverty

Crime

Grocery Quality

Restaurants

Parks

Sidewalks

Fast Food Outlets

Recreational

Facilities

Individual Factors

Dietary Intake

Physical Activity

Genetics

Family History

StressCoping

Eating Disorders

Psychological

Problems

Weight

Status

Chosen Neighborhoods

Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped

We then matched census-block groups within the income groups by population density and percentage of minority representation

One matched block group per income level was randomly selected

Prevalence of Obesity in

Block-Groups

0

5

10

15

20

25

30

35

40

45

50

Ag

e-a

dju

sted

Ob

esit

y P

rev

ale

nce

(

)

High-Income Low-Income

Age-standardized to the 1990 US Census

Density of Environmental Factors in the

Community Contributes to a ldquoToxicrdquo

Obesity Environment

0

2

4

6

8

10

12

14

16

18

Fast-food Convenience Store Bars

Den

sity

10

00

perso

ns

High-Income Low-Income

COMMUNITYrsquoS PERCEPTION OF SAFETY

0

5

10

15

20

25

30

35

40

Daytime Nighttime

Perc

en

t (

) F

eeli

ng

So

mew

hat

Safe

or

Un

safe

Low-Income High-Income

Percent Substandard (or worse) Housing

or Ground Conditions

of Residential Properties

0

10

20

30

Structural Grounds

Perc

en

t (

)

Low-Income High-Income

CONCLUSIONS

These data suggest that the higher

frequency of outlets providing

calorically-dense foods and alcohol may

contribute to greater obesity prevalence

in residents of low-income communities

More research is needed to thoroughly

document environmental determinants

of health and obesity

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

From 1994-1998 HUD randomly assigned

4498 women with children living in public

housing in high-poverty urban census

tracts to one of three groups (1) housing

vouchers redeemable only if they moved

to a low-poverty census tract (2)

unrestricted vouchers or (3) control group

(no vouchers)

Ludwig et al NEJM 201136516

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

10-12 year follow-up showed modest but

potentially important reductions in the

prevalence of extreme obesity amp diabetes in the

group moving from a neighborhood with high

poverty on one of low poverty compared to the

control group

No differences between the group receiving

traditional vouchers amp the control group

ldquoNeighborhoods matterrdquo

Ludwig et al NEJM 201136516

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance traffic safety in areas where

persons are or could be physically active

--Community-scale urban design amp land use policies to

promote physical activity including design components

to improve street lighting infrastructure projects to

increase safety of pedestrian street crossing and use of

traffic calming approaches such as speed humps amp

traffic circles are effective in increasing physical activity

--Both community-scale amp street-scale policies amp practices

are effective in increasing physical activity

Recommended Community Strategies Encourage Communities to Organize for Change

Participate in community coalitions or

partnerships to address obesity

--Little evidence is available to determine the

impact of community coalitions on obesity

prevention

--The presence of anti-smoking community

coalitions has been associated with lower rates

of tobacco consumption

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

$103 million awarded to 61 states and

communities including state amp local government

agencies tribes amp territories amp state amp local non-

profit organizations

To build capacity to implement changes for

community prevention efforts to ensure long-

term success

To implement evidence-based and practice-

based programs to improve health amp wellness

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Priority areas are

Tobacco-free living

Active living and healthy eating

Evidence-based quality clinical and other

preventive health services for prevention

and control of high blood pressure and

high cholesterol

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Applicants proposed specific activities in

line with their chosen priority areas in their

applications

Grantee activities will not be finalized until

plans are negotiated with CDC by early

2012

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Capacity-Building Award

The Confederated Tribes of The Chehalis

Reservation is receiving a $498663 planning

award to build capacity to support healthy

lifestyles among their tribal population of 1500

in Washington State

Work will target tobacco-free living active living

and healthy eating and quality clinical and other

healthy serviceswwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Implementation Award

Austin TX Dept of Health and Human Services

is receiving $1026158 to serve Travis County

(Austin) to expand efforts in tobacco-free living

active living and healthy eating quality clinical

and other preventive services social and

emotional wellness and healthy and safe

physical environmentswwwcdcgov1052011

Building sustainable healthy

communities Bottom line

Obesity is an environmental problem

Despite progress in genetic research public health advances only will occur when we take the environment seriously

Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment

Until we do this we will not make substantial progress in addressing the epidemic of obesity

Poston amp Foreyt Atherosclerosis 1999

Whatrsquos the best approach

Integrate all sectors of society into community

change interventions

Incorporate

Science amp Technology

Education

FamilyCommunity

Healthcare

Arts amp Entertainment

Law amp Politics

Commerce amp Trade

Sectors of Society

Arts amp Entertainm

ent

Commerce amp Trade

Education

FamilyCommunity

Healthcare

Law amp Politics

Science amp Technology

Project FIT rationale design and baseline characteristics of a school- and community-

based intervention to address physical activity and healthy eating among low-income

elementary school children

Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D

Oh HJ Orth J Randall S Mayfield K Holmes D

Source

Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu

Abstract

BACKGROUND

This paper describes Project FIT a collaboration between the public school system local

health systems physicians neighborhood associations businesses faith-based leaders

community agencies and university researchers to develop a multi-faceted approach to

promote physical activity and healthy eating toward the general goal of preventing and

reducing childhood obesity among children in Grand Rapids MI USA

METHODSDESIGN

There are four overall components to Project FIT school community social marketing and

school staff wellness - all that focus on 1) increasing access to safe and affordable physical

activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)

improving the affordability and availability of nutritious food in the neighborhoods surrounding

the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding

nutrition and physical activity among school staff parents and students 4) impacting the

culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging

dialogue among all community partners to leverage existing programs and introduce new

ones

Realistic Management Goals

5-10 weight loss

Health energy and fitness

Well-being and self-esteem

Mood and appearance

Functional and recreational

activity

Key Elements

Focus on health and energy

Food and physical activity diaries

Gradual increase in physical activity

Gradual reduction in dietary fat

No feelings of food deprivation

Social support groups

Recommended Strategies for Building

Sustainable Healthy Communities

Overview from USA

Promote the availability of affordable healthy

food and beverages

Support healthy food and beverage choices

Encourage breastfeeding

Encourage physical activity or limit sedentary

activity among children amp youth

Create safe communities that support physical

activity

Encourage communities to organize for change

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Increase the availability of healthier food and

beverage choices in public service venues (eg

schools city amp county buildings etc)

--Insufficient evidence in school-based programs

--Associations suggest availability amp increased

consumption

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve availability of affordable healthier

food amp beverage choices in public service

venues

--Reducing the cost of healthier foods

increases their purchase

--Providing coupons redeemable for

healthier foods increases their purchase

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve geographic availability of

supermarkets in underserved areas

-- Greater access to nearby supermarkets is

associated with healthier eating behaviors

-- Increasing the number of supermarkets in

underserved neighborhoods increased

real estate values increased economic

activity amp employment amp resulted in lower

food prices

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Provide incentives to food retailers to locate in

andor offer healthier food choices in

underserved areas

-- Presence of retail venues that provide healthier

foods is associated with better nutrition

-- Greater availability of supermarkets was

associated with lower adolescent BMI scores

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Improve availability of mechanisms for

purchasing foods from farms

--Evidence supporting a direct link between

purchasing food from farms amp improved diet is

limited

--Two studies of initiatives to encourage

participation in farmersrsquo market showed

increased intention to eat more fruits amp

vegetables but no direct evidence

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Provide incentives for the production

distribution and procurement of foods from local

farms

--No evidence has been published to link local

food production amp health outcomes

--There is a current study exploring the potential

nutritional amp health benefits of eating locally

grown foods

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Restrict availability of less healthy foods amp

beverages in public service venues

--No peer-reviewed studies examined the impact

designed to restrict availability of less healthy

foods in public service venues

--21 states have policies that restrict the sale of

competitive foods in schools beyond USDA

regulations however no studies have evaluated

the impact of the policies

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Institute smaller portion size options in public

service venues

--Evidence is lacking to demonstrate effectiveness

of population-based interventions aimed at

reducing portion sizes in public service venues

--Evidence from clinical studies in laboratories

demonstrates decreasing portion sizes

decreases energy intake

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Limit advertisements of less healthy foods amp

beverages

--Little evidence is available regarding the impact

of restricting advertising on purchasing amp

consumption of less healthy foods

--Cross-sectional time-series studies of tobacco-

control efforts suggest an association between

advertising bans amp decreased tobacco

consumption

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Discourage consumption of sugar-sweetened

beverages

--One longitudinal study of a school-based

intervention among Native-American high school

students showed a substantial reduction in

sugar-sweetened beverages over a 3-year

period

--A RCT of a home-based intervention that

eliminated sugar-sweetened beverages showed

reduction in BMI scores

Recommended Community Strategies Strategies to encourage breastfeeding

Increase support for breastfeeding

--Evidence directly linking environmental

interventions that support breastfeeding with

obesity-related outcomes is lacking

--Epidemiologic studies indicate that breastfeeding

helps prevent pediatric obesity

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Require physical education in schools

--14 studies have demonstrated that school-based

PE was effective in increasing levels of physical

activity and improving physical fitness

--Minimum of 150 minwk in elementary schools

225 minwk in middle schools and high schools

throughout the school year as recommended by

NASPE

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Increase opportunities for extracurricular

physical activity

--Participation in after-school programs increased

studentsrsquo level of physical activity amp improved

obesity-related outcomes (improved CV fitness

reduced body fat)

--2 pilot studies providing extracurricular physical

activity showed increased levels of PA amp

decreased sedentary behavior

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Reduce screen time in public service venues

--A school-based RCT indicated that children who

reduced their television videotape amp video

game use had significant decrease in BMI tricep

skin fold thickness amp waist circumference

compared to controls

--Spending less time watching television is

associated with increased physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Improve access to outdoor recreational

facilities

--Review of 108 studies indicated that access to facilities

and programs for recreation near their homes amp time

spent outdoors correlated positively with increased

physical activity among childrenamp adults

--Perceptions that footpaths are safe for walking was

significantly associated with adults being classified as

physically active at a level sufficient for health benefits

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting

bicycling

--Longitudinal intervention studies have

demonstrated that improving bicycling

infrastructure is associated with increased

frequency of bicycling

--Cross-sectional studies indicated a significant

association between bicycling infrastructure amp

frequency of biking

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting walking

--Reviews of cross-sectional studies of

environmental correlates of physical activity amp

walking generally find a positive association

between infrastructure supportive of walking amp

physical activity

--Identifying amp creating safe routes to school

together with educational components

increased the number of students walking to

school

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Locating schools within easy walking

distance of residential areas

--Community-scale urban design amp land use policies amp

practices including locating schools stores workplaces

amp recreation areas close to residential areas are

effective in facilitating an increase in levels of physical

activity

--Majority of efforts to encourage walking to school involve

improving the routes rather than improving the location

of schools

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Improve access to public transportation

--Insufficient evidence exists to determine

effectiveness of transportation policies in

increasing the level of physical activity or

improving fitness

--1 study indicated that 29 of individuals who

walk to and from public transit achieve at least

30 minutes of daily physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Zone for mixed-use development

--Allows residential commercial institutional amp

other public land uses to be located in close

proximity to one another

--Studies using correlation analyses amp regression

models indicated that mixed land use was

associated with increased walking amp cycling

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance personal safety in areas where

persons are or could be physically active

--Cross-sectional studies have demonstrated a

negative relationship between crime rates andor

perceived safety amp physical activity in

neighborhoods

--Few intervention studies have evaluated the

impact of policies amp practices to improve

personal safety on physical activity

Geospatial Mapping Linking Urban

Environments to Health Risk

Measure association between environmental variables amp health risk factors

Assess relationships between variables at different levels of analysis

Used in conjunction with linear analyses

Our Community Environmental Model

of Obesity

Community Factors

Poverty

Crime

Grocery Quality

Restaurants

Parks

Sidewalks

Fast Food Outlets

Recreational

Facilities

Individual Factors

Dietary Intake

Physical Activity

Genetics

Family History

StressCoping

Eating Disorders

Psychological

Problems

Weight

Status

Chosen Neighborhoods

Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped

We then matched census-block groups within the income groups by population density and percentage of minority representation

One matched block group per income level was randomly selected

Prevalence of Obesity in

Block-Groups

0

5

10

15

20

25

30

35

40

45

50

Ag

e-a

dju

sted

Ob

esit

y P

rev

ale

nce

(

)

High-Income Low-Income

Age-standardized to the 1990 US Census

Density of Environmental Factors in the

Community Contributes to a ldquoToxicrdquo

Obesity Environment

0

2

4

6

8

10

12

14

16

18

Fast-food Convenience Store Bars

Den

sity

10

00

perso

ns

High-Income Low-Income

COMMUNITYrsquoS PERCEPTION OF SAFETY

0

5

10

15

20

25

30

35

40

Daytime Nighttime

Perc

en

t (

) F

eeli

ng

So

mew

hat

Safe

or

Un

safe

Low-Income High-Income

Percent Substandard (or worse) Housing

or Ground Conditions

of Residential Properties

0

10

20

30

Structural Grounds

Perc

en

t (

)

Low-Income High-Income

CONCLUSIONS

These data suggest that the higher

frequency of outlets providing

calorically-dense foods and alcohol may

contribute to greater obesity prevalence

in residents of low-income communities

More research is needed to thoroughly

document environmental determinants

of health and obesity

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

From 1994-1998 HUD randomly assigned

4498 women with children living in public

housing in high-poverty urban census

tracts to one of three groups (1) housing

vouchers redeemable only if they moved

to a low-poverty census tract (2)

unrestricted vouchers or (3) control group

(no vouchers)

Ludwig et al NEJM 201136516

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

10-12 year follow-up showed modest but

potentially important reductions in the

prevalence of extreme obesity amp diabetes in the

group moving from a neighborhood with high

poverty on one of low poverty compared to the

control group

No differences between the group receiving

traditional vouchers amp the control group

ldquoNeighborhoods matterrdquo

Ludwig et al NEJM 201136516

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance traffic safety in areas where

persons are or could be physically active

--Community-scale urban design amp land use policies to

promote physical activity including design components

to improve street lighting infrastructure projects to

increase safety of pedestrian street crossing and use of

traffic calming approaches such as speed humps amp

traffic circles are effective in increasing physical activity

--Both community-scale amp street-scale policies amp practices

are effective in increasing physical activity

Recommended Community Strategies Encourage Communities to Organize for Change

Participate in community coalitions or

partnerships to address obesity

--Little evidence is available to determine the

impact of community coalitions on obesity

prevention

--The presence of anti-smoking community

coalitions has been associated with lower rates

of tobacco consumption

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

$103 million awarded to 61 states and

communities including state amp local government

agencies tribes amp territories amp state amp local non-

profit organizations

To build capacity to implement changes for

community prevention efforts to ensure long-

term success

To implement evidence-based and practice-

based programs to improve health amp wellness

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Priority areas are

Tobacco-free living

Active living and healthy eating

Evidence-based quality clinical and other

preventive health services for prevention

and control of high blood pressure and

high cholesterol

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Applicants proposed specific activities in

line with their chosen priority areas in their

applications

Grantee activities will not be finalized until

plans are negotiated with CDC by early

2012

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Capacity-Building Award

The Confederated Tribes of The Chehalis

Reservation is receiving a $498663 planning

award to build capacity to support healthy

lifestyles among their tribal population of 1500

in Washington State

Work will target tobacco-free living active living

and healthy eating and quality clinical and other

healthy serviceswwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Implementation Award

Austin TX Dept of Health and Human Services

is receiving $1026158 to serve Travis County

(Austin) to expand efforts in tobacco-free living

active living and healthy eating quality clinical

and other preventive services social and

emotional wellness and healthy and safe

physical environmentswwwcdcgov1052011

Building sustainable healthy

communities Bottom line

Obesity is an environmental problem

Despite progress in genetic research public health advances only will occur when we take the environment seriously

Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment

Until we do this we will not make substantial progress in addressing the epidemic of obesity

Poston amp Foreyt Atherosclerosis 1999

Whatrsquos the best approach

Integrate all sectors of society into community

change interventions

Incorporate

Science amp Technology

Education

FamilyCommunity

Healthcare

Arts amp Entertainment

Law amp Politics

Commerce amp Trade

Sectors of Society

Arts amp Entertainm

ent

Commerce amp Trade

Education

FamilyCommunity

Healthcare

Law amp Politics

Science amp Technology

Project FIT rationale design and baseline characteristics of a school- and community-

based intervention to address physical activity and healthy eating among low-income

elementary school children

Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D

Oh HJ Orth J Randall S Mayfield K Holmes D

Source

Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu

Abstract

BACKGROUND

This paper describes Project FIT a collaboration between the public school system local

health systems physicians neighborhood associations businesses faith-based leaders

community agencies and university researchers to develop a multi-faceted approach to

promote physical activity and healthy eating toward the general goal of preventing and

reducing childhood obesity among children in Grand Rapids MI USA

METHODSDESIGN

There are four overall components to Project FIT school community social marketing and

school staff wellness - all that focus on 1) increasing access to safe and affordable physical

activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)

improving the affordability and availability of nutritious food in the neighborhoods surrounding

the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding

nutrition and physical activity among school staff parents and students 4) impacting the

culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging

dialogue among all community partners to leverage existing programs and introduce new

ones

Key Elements

Focus on health and energy

Food and physical activity diaries

Gradual increase in physical activity

Gradual reduction in dietary fat

No feelings of food deprivation

Social support groups

Recommended Strategies for Building

Sustainable Healthy Communities

Overview from USA

Promote the availability of affordable healthy

food and beverages

Support healthy food and beverage choices

Encourage breastfeeding

Encourage physical activity or limit sedentary

activity among children amp youth

Create safe communities that support physical

activity

Encourage communities to organize for change

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Increase the availability of healthier food and

beverage choices in public service venues (eg

schools city amp county buildings etc)

--Insufficient evidence in school-based programs

--Associations suggest availability amp increased

consumption

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve availability of affordable healthier

food amp beverage choices in public service

venues

--Reducing the cost of healthier foods

increases their purchase

--Providing coupons redeemable for

healthier foods increases their purchase

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve geographic availability of

supermarkets in underserved areas

-- Greater access to nearby supermarkets is

associated with healthier eating behaviors

-- Increasing the number of supermarkets in

underserved neighborhoods increased

real estate values increased economic

activity amp employment amp resulted in lower

food prices

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Provide incentives to food retailers to locate in

andor offer healthier food choices in

underserved areas

-- Presence of retail venues that provide healthier

foods is associated with better nutrition

-- Greater availability of supermarkets was

associated with lower adolescent BMI scores

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Improve availability of mechanisms for

purchasing foods from farms

--Evidence supporting a direct link between

purchasing food from farms amp improved diet is

limited

--Two studies of initiatives to encourage

participation in farmersrsquo market showed

increased intention to eat more fruits amp

vegetables but no direct evidence

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Provide incentives for the production

distribution and procurement of foods from local

farms

--No evidence has been published to link local

food production amp health outcomes

--There is a current study exploring the potential

nutritional amp health benefits of eating locally

grown foods

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Restrict availability of less healthy foods amp

beverages in public service venues

--No peer-reviewed studies examined the impact

designed to restrict availability of less healthy

foods in public service venues

--21 states have policies that restrict the sale of

competitive foods in schools beyond USDA

regulations however no studies have evaluated

the impact of the policies

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Institute smaller portion size options in public

service venues

--Evidence is lacking to demonstrate effectiveness

of population-based interventions aimed at

reducing portion sizes in public service venues

--Evidence from clinical studies in laboratories

demonstrates decreasing portion sizes

decreases energy intake

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Limit advertisements of less healthy foods amp

beverages

--Little evidence is available regarding the impact

of restricting advertising on purchasing amp

consumption of less healthy foods

--Cross-sectional time-series studies of tobacco-

control efforts suggest an association between

advertising bans amp decreased tobacco

consumption

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Discourage consumption of sugar-sweetened

beverages

--One longitudinal study of a school-based

intervention among Native-American high school

students showed a substantial reduction in

sugar-sweetened beverages over a 3-year

period

--A RCT of a home-based intervention that

eliminated sugar-sweetened beverages showed

reduction in BMI scores

Recommended Community Strategies Strategies to encourage breastfeeding

Increase support for breastfeeding

--Evidence directly linking environmental

interventions that support breastfeeding with

obesity-related outcomes is lacking

--Epidemiologic studies indicate that breastfeeding

helps prevent pediatric obesity

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Require physical education in schools

--14 studies have demonstrated that school-based

PE was effective in increasing levels of physical

activity and improving physical fitness

--Minimum of 150 minwk in elementary schools

225 minwk in middle schools and high schools

throughout the school year as recommended by

NASPE

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Increase opportunities for extracurricular

physical activity

--Participation in after-school programs increased

studentsrsquo level of physical activity amp improved

obesity-related outcomes (improved CV fitness

reduced body fat)

--2 pilot studies providing extracurricular physical

activity showed increased levels of PA amp

decreased sedentary behavior

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Reduce screen time in public service venues

--A school-based RCT indicated that children who

reduced their television videotape amp video

game use had significant decrease in BMI tricep

skin fold thickness amp waist circumference

compared to controls

--Spending less time watching television is

associated with increased physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Improve access to outdoor recreational

facilities

--Review of 108 studies indicated that access to facilities

and programs for recreation near their homes amp time

spent outdoors correlated positively with increased

physical activity among childrenamp adults

--Perceptions that footpaths are safe for walking was

significantly associated with adults being classified as

physically active at a level sufficient for health benefits

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting

bicycling

--Longitudinal intervention studies have

demonstrated that improving bicycling

infrastructure is associated with increased

frequency of bicycling

--Cross-sectional studies indicated a significant

association between bicycling infrastructure amp

frequency of biking

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting walking

--Reviews of cross-sectional studies of

environmental correlates of physical activity amp

walking generally find a positive association

between infrastructure supportive of walking amp

physical activity

--Identifying amp creating safe routes to school

together with educational components

increased the number of students walking to

school

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Locating schools within easy walking

distance of residential areas

--Community-scale urban design amp land use policies amp

practices including locating schools stores workplaces

amp recreation areas close to residential areas are

effective in facilitating an increase in levels of physical

activity

--Majority of efforts to encourage walking to school involve

improving the routes rather than improving the location

of schools

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Improve access to public transportation

--Insufficient evidence exists to determine

effectiveness of transportation policies in

increasing the level of physical activity or

improving fitness

--1 study indicated that 29 of individuals who

walk to and from public transit achieve at least

30 minutes of daily physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Zone for mixed-use development

--Allows residential commercial institutional amp

other public land uses to be located in close

proximity to one another

--Studies using correlation analyses amp regression

models indicated that mixed land use was

associated with increased walking amp cycling

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance personal safety in areas where

persons are or could be physically active

--Cross-sectional studies have demonstrated a

negative relationship between crime rates andor

perceived safety amp physical activity in

neighborhoods

--Few intervention studies have evaluated the

impact of policies amp practices to improve

personal safety on physical activity

Geospatial Mapping Linking Urban

Environments to Health Risk

Measure association between environmental variables amp health risk factors

Assess relationships between variables at different levels of analysis

Used in conjunction with linear analyses

Our Community Environmental Model

of Obesity

Community Factors

Poverty

Crime

Grocery Quality

Restaurants

Parks

Sidewalks

Fast Food Outlets

Recreational

Facilities

Individual Factors

Dietary Intake

Physical Activity

Genetics

Family History

StressCoping

Eating Disorders

Psychological

Problems

Weight

Status

Chosen Neighborhoods

Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped

We then matched census-block groups within the income groups by population density and percentage of minority representation

One matched block group per income level was randomly selected

Prevalence of Obesity in

Block-Groups

0

5

10

15

20

25

30

35

40

45

50

Ag

e-a

dju

sted

Ob

esit

y P

rev

ale

nce

(

)

High-Income Low-Income

Age-standardized to the 1990 US Census

Density of Environmental Factors in the

Community Contributes to a ldquoToxicrdquo

Obesity Environment

0

2

4

6

8

10

12

14

16

18

Fast-food Convenience Store Bars

Den

sity

10

00

perso

ns

High-Income Low-Income

COMMUNITYrsquoS PERCEPTION OF SAFETY

0

5

10

15

20

25

30

35

40

Daytime Nighttime

Perc

en

t (

) F

eeli

ng

So

mew

hat

Safe

or

Un

safe

Low-Income High-Income

Percent Substandard (or worse) Housing

or Ground Conditions

of Residential Properties

0

10

20

30

Structural Grounds

Perc

en

t (

)

Low-Income High-Income

CONCLUSIONS

These data suggest that the higher

frequency of outlets providing

calorically-dense foods and alcohol may

contribute to greater obesity prevalence

in residents of low-income communities

More research is needed to thoroughly

document environmental determinants

of health and obesity

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

From 1994-1998 HUD randomly assigned

4498 women with children living in public

housing in high-poverty urban census

tracts to one of three groups (1) housing

vouchers redeemable only if they moved

to a low-poverty census tract (2)

unrestricted vouchers or (3) control group

(no vouchers)

Ludwig et al NEJM 201136516

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

10-12 year follow-up showed modest but

potentially important reductions in the

prevalence of extreme obesity amp diabetes in the

group moving from a neighborhood with high

poverty on one of low poverty compared to the

control group

No differences between the group receiving

traditional vouchers amp the control group

ldquoNeighborhoods matterrdquo

Ludwig et al NEJM 201136516

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance traffic safety in areas where

persons are or could be physically active

--Community-scale urban design amp land use policies to

promote physical activity including design components

to improve street lighting infrastructure projects to

increase safety of pedestrian street crossing and use of

traffic calming approaches such as speed humps amp

traffic circles are effective in increasing physical activity

--Both community-scale amp street-scale policies amp practices

are effective in increasing physical activity

Recommended Community Strategies Encourage Communities to Organize for Change

Participate in community coalitions or

partnerships to address obesity

--Little evidence is available to determine the

impact of community coalitions on obesity

prevention

--The presence of anti-smoking community

coalitions has been associated with lower rates

of tobacco consumption

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

$103 million awarded to 61 states and

communities including state amp local government

agencies tribes amp territories amp state amp local non-

profit organizations

To build capacity to implement changes for

community prevention efforts to ensure long-

term success

To implement evidence-based and practice-

based programs to improve health amp wellness

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Priority areas are

Tobacco-free living

Active living and healthy eating

Evidence-based quality clinical and other

preventive health services for prevention

and control of high blood pressure and

high cholesterol

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Applicants proposed specific activities in

line with their chosen priority areas in their

applications

Grantee activities will not be finalized until

plans are negotiated with CDC by early

2012

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Capacity-Building Award

The Confederated Tribes of The Chehalis

Reservation is receiving a $498663 planning

award to build capacity to support healthy

lifestyles among their tribal population of 1500

in Washington State

Work will target tobacco-free living active living

and healthy eating and quality clinical and other

healthy serviceswwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Implementation Award

Austin TX Dept of Health and Human Services

is receiving $1026158 to serve Travis County

(Austin) to expand efforts in tobacco-free living

active living and healthy eating quality clinical

and other preventive services social and

emotional wellness and healthy and safe

physical environmentswwwcdcgov1052011

Building sustainable healthy

communities Bottom line

Obesity is an environmental problem

Despite progress in genetic research public health advances only will occur when we take the environment seriously

Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment

Until we do this we will not make substantial progress in addressing the epidemic of obesity

Poston amp Foreyt Atherosclerosis 1999

Whatrsquos the best approach

Integrate all sectors of society into community

change interventions

Incorporate

Science amp Technology

Education

FamilyCommunity

Healthcare

Arts amp Entertainment

Law amp Politics

Commerce amp Trade

Sectors of Society

Arts amp Entertainm

ent

Commerce amp Trade

Education

FamilyCommunity

Healthcare

Law amp Politics

Science amp Technology

Project FIT rationale design and baseline characteristics of a school- and community-

based intervention to address physical activity and healthy eating among low-income

elementary school children

Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D

Oh HJ Orth J Randall S Mayfield K Holmes D

Source

Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu

Abstract

BACKGROUND

This paper describes Project FIT a collaboration between the public school system local

health systems physicians neighborhood associations businesses faith-based leaders

community agencies and university researchers to develop a multi-faceted approach to

promote physical activity and healthy eating toward the general goal of preventing and

reducing childhood obesity among children in Grand Rapids MI USA

METHODSDESIGN

There are four overall components to Project FIT school community social marketing and

school staff wellness - all that focus on 1) increasing access to safe and affordable physical

activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)

improving the affordability and availability of nutritious food in the neighborhoods surrounding

the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding

nutrition and physical activity among school staff parents and students 4) impacting the

culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging

dialogue among all community partners to leverage existing programs and introduce new

ones

Recommended Strategies for Building

Sustainable Healthy Communities

Overview from USA

Promote the availability of affordable healthy

food and beverages

Support healthy food and beverage choices

Encourage breastfeeding

Encourage physical activity or limit sedentary

activity among children amp youth

Create safe communities that support physical

activity

Encourage communities to organize for change

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Increase the availability of healthier food and

beverage choices in public service venues (eg

schools city amp county buildings etc)

--Insufficient evidence in school-based programs

--Associations suggest availability amp increased

consumption

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve availability of affordable healthier

food amp beverage choices in public service

venues

--Reducing the cost of healthier foods

increases their purchase

--Providing coupons redeemable for

healthier foods increases their purchase

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve geographic availability of

supermarkets in underserved areas

-- Greater access to nearby supermarkets is

associated with healthier eating behaviors

-- Increasing the number of supermarkets in

underserved neighborhoods increased

real estate values increased economic

activity amp employment amp resulted in lower

food prices

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Provide incentives to food retailers to locate in

andor offer healthier food choices in

underserved areas

-- Presence of retail venues that provide healthier

foods is associated with better nutrition

-- Greater availability of supermarkets was

associated with lower adolescent BMI scores

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Improve availability of mechanisms for

purchasing foods from farms

--Evidence supporting a direct link between

purchasing food from farms amp improved diet is

limited

--Two studies of initiatives to encourage

participation in farmersrsquo market showed

increased intention to eat more fruits amp

vegetables but no direct evidence

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Provide incentives for the production

distribution and procurement of foods from local

farms

--No evidence has been published to link local

food production amp health outcomes

--There is a current study exploring the potential

nutritional amp health benefits of eating locally

grown foods

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Restrict availability of less healthy foods amp

beverages in public service venues

--No peer-reviewed studies examined the impact

designed to restrict availability of less healthy

foods in public service venues

--21 states have policies that restrict the sale of

competitive foods in schools beyond USDA

regulations however no studies have evaluated

the impact of the policies

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Institute smaller portion size options in public

service venues

--Evidence is lacking to demonstrate effectiveness

of population-based interventions aimed at

reducing portion sizes in public service venues

--Evidence from clinical studies in laboratories

demonstrates decreasing portion sizes

decreases energy intake

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Limit advertisements of less healthy foods amp

beverages

--Little evidence is available regarding the impact

of restricting advertising on purchasing amp

consumption of less healthy foods

--Cross-sectional time-series studies of tobacco-

control efforts suggest an association between

advertising bans amp decreased tobacco

consumption

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Discourage consumption of sugar-sweetened

beverages

--One longitudinal study of a school-based

intervention among Native-American high school

students showed a substantial reduction in

sugar-sweetened beverages over a 3-year

period

--A RCT of a home-based intervention that

eliminated sugar-sweetened beverages showed

reduction in BMI scores

Recommended Community Strategies Strategies to encourage breastfeeding

Increase support for breastfeeding

--Evidence directly linking environmental

interventions that support breastfeeding with

obesity-related outcomes is lacking

--Epidemiologic studies indicate that breastfeeding

helps prevent pediatric obesity

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Require physical education in schools

--14 studies have demonstrated that school-based

PE was effective in increasing levels of physical

activity and improving physical fitness

--Minimum of 150 minwk in elementary schools

225 minwk in middle schools and high schools

throughout the school year as recommended by

NASPE

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Increase opportunities for extracurricular

physical activity

--Participation in after-school programs increased

studentsrsquo level of physical activity amp improved

obesity-related outcomes (improved CV fitness

reduced body fat)

--2 pilot studies providing extracurricular physical

activity showed increased levels of PA amp

decreased sedentary behavior

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Reduce screen time in public service venues

--A school-based RCT indicated that children who

reduced their television videotape amp video

game use had significant decrease in BMI tricep

skin fold thickness amp waist circumference

compared to controls

--Spending less time watching television is

associated with increased physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Improve access to outdoor recreational

facilities

--Review of 108 studies indicated that access to facilities

and programs for recreation near their homes amp time

spent outdoors correlated positively with increased

physical activity among childrenamp adults

--Perceptions that footpaths are safe for walking was

significantly associated with adults being classified as

physically active at a level sufficient for health benefits

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting

bicycling

--Longitudinal intervention studies have

demonstrated that improving bicycling

infrastructure is associated with increased

frequency of bicycling

--Cross-sectional studies indicated a significant

association between bicycling infrastructure amp

frequency of biking

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting walking

--Reviews of cross-sectional studies of

environmental correlates of physical activity amp

walking generally find a positive association

between infrastructure supportive of walking amp

physical activity

--Identifying amp creating safe routes to school

together with educational components

increased the number of students walking to

school

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Locating schools within easy walking

distance of residential areas

--Community-scale urban design amp land use policies amp

practices including locating schools stores workplaces

amp recreation areas close to residential areas are

effective in facilitating an increase in levels of physical

activity

--Majority of efforts to encourage walking to school involve

improving the routes rather than improving the location

of schools

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Improve access to public transportation

--Insufficient evidence exists to determine

effectiveness of transportation policies in

increasing the level of physical activity or

improving fitness

--1 study indicated that 29 of individuals who

walk to and from public transit achieve at least

30 minutes of daily physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Zone for mixed-use development

--Allows residential commercial institutional amp

other public land uses to be located in close

proximity to one another

--Studies using correlation analyses amp regression

models indicated that mixed land use was

associated with increased walking amp cycling

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance personal safety in areas where

persons are or could be physically active

--Cross-sectional studies have demonstrated a

negative relationship between crime rates andor

perceived safety amp physical activity in

neighborhoods

--Few intervention studies have evaluated the

impact of policies amp practices to improve

personal safety on physical activity

Geospatial Mapping Linking Urban

Environments to Health Risk

Measure association between environmental variables amp health risk factors

Assess relationships between variables at different levels of analysis

Used in conjunction with linear analyses

Our Community Environmental Model

of Obesity

Community Factors

Poverty

Crime

Grocery Quality

Restaurants

Parks

Sidewalks

Fast Food Outlets

Recreational

Facilities

Individual Factors

Dietary Intake

Physical Activity

Genetics

Family History

StressCoping

Eating Disorders

Psychological

Problems

Weight

Status

Chosen Neighborhoods

Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped

We then matched census-block groups within the income groups by population density and percentage of minority representation

One matched block group per income level was randomly selected

Prevalence of Obesity in

Block-Groups

0

5

10

15

20

25

30

35

40

45

50

Ag

e-a

dju

sted

Ob

esit

y P

rev

ale

nce

(

)

High-Income Low-Income

Age-standardized to the 1990 US Census

Density of Environmental Factors in the

Community Contributes to a ldquoToxicrdquo

Obesity Environment

0

2

4

6

8

10

12

14

16

18

Fast-food Convenience Store Bars

Den

sity

10

00

perso

ns

High-Income Low-Income

COMMUNITYrsquoS PERCEPTION OF SAFETY

0

5

10

15

20

25

30

35

40

Daytime Nighttime

Perc

en

t (

) F

eeli

ng

So

mew

hat

Safe

or

Un

safe

Low-Income High-Income

Percent Substandard (or worse) Housing

or Ground Conditions

of Residential Properties

0

10

20

30

Structural Grounds

Perc

en

t (

)

Low-Income High-Income

CONCLUSIONS

These data suggest that the higher

frequency of outlets providing

calorically-dense foods and alcohol may

contribute to greater obesity prevalence

in residents of low-income communities

More research is needed to thoroughly

document environmental determinants

of health and obesity

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

From 1994-1998 HUD randomly assigned

4498 women with children living in public

housing in high-poverty urban census

tracts to one of three groups (1) housing

vouchers redeemable only if they moved

to a low-poverty census tract (2)

unrestricted vouchers or (3) control group

(no vouchers)

Ludwig et al NEJM 201136516

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

10-12 year follow-up showed modest but

potentially important reductions in the

prevalence of extreme obesity amp diabetes in the

group moving from a neighborhood with high

poverty on one of low poverty compared to the

control group

No differences between the group receiving

traditional vouchers amp the control group

ldquoNeighborhoods matterrdquo

Ludwig et al NEJM 201136516

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance traffic safety in areas where

persons are or could be physically active

--Community-scale urban design amp land use policies to

promote physical activity including design components

to improve street lighting infrastructure projects to

increase safety of pedestrian street crossing and use of

traffic calming approaches such as speed humps amp

traffic circles are effective in increasing physical activity

--Both community-scale amp street-scale policies amp practices

are effective in increasing physical activity

Recommended Community Strategies Encourage Communities to Organize for Change

Participate in community coalitions or

partnerships to address obesity

--Little evidence is available to determine the

impact of community coalitions on obesity

prevention

--The presence of anti-smoking community

coalitions has been associated with lower rates

of tobacco consumption

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

$103 million awarded to 61 states and

communities including state amp local government

agencies tribes amp territories amp state amp local non-

profit organizations

To build capacity to implement changes for

community prevention efforts to ensure long-

term success

To implement evidence-based and practice-

based programs to improve health amp wellness

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Priority areas are

Tobacco-free living

Active living and healthy eating

Evidence-based quality clinical and other

preventive health services for prevention

and control of high blood pressure and

high cholesterol

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Applicants proposed specific activities in

line with their chosen priority areas in their

applications

Grantee activities will not be finalized until

plans are negotiated with CDC by early

2012

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Capacity-Building Award

The Confederated Tribes of The Chehalis

Reservation is receiving a $498663 planning

award to build capacity to support healthy

lifestyles among their tribal population of 1500

in Washington State

Work will target tobacco-free living active living

and healthy eating and quality clinical and other

healthy serviceswwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Implementation Award

Austin TX Dept of Health and Human Services

is receiving $1026158 to serve Travis County

(Austin) to expand efforts in tobacco-free living

active living and healthy eating quality clinical

and other preventive services social and

emotional wellness and healthy and safe

physical environmentswwwcdcgov1052011

Building sustainable healthy

communities Bottom line

Obesity is an environmental problem

Despite progress in genetic research public health advances only will occur when we take the environment seriously

Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment

Until we do this we will not make substantial progress in addressing the epidemic of obesity

Poston amp Foreyt Atherosclerosis 1999

Whatrsquos the best approach

Integrate all sectors of society into community

change interventions

Incorporate

Science amp Technology

Education

FamilyCommunity

Healthcare

Arts amp Entertainment

Law amp Politics

Commerce amp Trade

Sectors of Society

Arts amp Entertainm

ent

Commerce amp Trade

Education

FamilyCommunity

Healthcare

Law amp Politics

Science amp Technology

Project FIT rationale design and baseline characteristics of a school- and community-

based intervention to address physical activity and healthy eating among low-income

elementary school children

Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D

Oh HJ Orth J Randall S Mayfield K Holmes D

Source

Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu

Abstract

BACKGROUND

This paper describes Project FIT a collaboration between the public school system local

health systems physicians neighborhood associations businesses faith-based leaders

community agencies and university researchers to develop a multi-faceted approach to

promote physical activity and healthy eating toward the general goal of preventing and

reducing childhood obesity among children in Grand Rapids MI USA

METHODSDESIGN

There are four overall components to Project FIT school community social marketing and

school staff wellness - all that focus on 1) increasing access to safe and affordable physical

activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)

improving the affordability and availability of nutritious food in the neighborhoods surrounding

the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding

nutrition and physical activity among school staff parents and students 4) impacting the

culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging

dialogue among all community partners to leverage existing programs and introduce new

ones

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Increase the availability of healthier food and

beverage choices in public service venues (eg

schools city amp county buildings etc)

--Insufficient evidence in school-based programs

--Associations suggest availability amp increased

consumption

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve availability of affordable healthier

food amp beverage choices in public service

venues

--Reducing the cost of healthier foods

increases their purchase

--Providing coupons redeemable for

healthier foods increases their purchase

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve geographic availability of

supermarkets in underserved areas

-- Greater access to nearby supermarkets is

associated with healthier eating behaviors

-- Increasing the number of supermarkets in

underserved neighborhoods increased

real estate values increased economic

activity amp employment amp resulted in lower

food prices

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Provide incentives to food retailers to locate in

andor offer healthier food choices in

underserved areas

-- Presence of retail venues that provide healthier

foods is associated with better nutrition

-- Greater availability of supermarkets was

associated with lower adolescent BMI scores

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Improve availability of mechanisms for

purchasing foods from farms

--Evidence supporting a direct link between

purchasing food from farms amp improved diet is

limited

--Two studies of initiatives to encourage

participation in farmersrsquo market showed

increased intention to eat more fruits amp

vegetables but no direct evidence

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Provide incentives for the production

distribution and procurement of foods from local

farms

--No evidence has been published to link local

food production amp health outcomes

--There is a current study exploring the potential

nutritional amp health benefits of eating locally

grown foods

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Restrict availability of less healthy foods amp

beverages in public service venues

--No peer-reviewed studies examined the impact

designed to restrict availability of less healthy

foods in public service venues

--21 states have policies that restrict the sale of

competitive foods in schools beyond USDA

regulations however no studies have evaluated

the impact of the policies

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Institute smaller portion size options in public

service venues

--Evidence is lacking to demonstrate effectiveness

of population-based interventions aimed at

reducing portion sizes in public service venues

--Evidence from clinical studies in laboratories

demonstrates decreasing portion sizes

decreases energy intake

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Limit advertisements of less healthy foods amp

beverages

--Little evidence is available regarding the impact

of restricting advertising on purchasing amp

consumption of less healthy foods

--Cross-sectional time-series studies of tobacco-

control efforts suggest an association between

advertising bans amp decreased tobacco

consumption

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Discourage consumption of sugar-sweetened

beverages

--One longitudinal study of a school-based

intervention among Native-American high school

students showed a substantial reduction in

sugar-sweetened beverages over a 3-year

period

--A RCT of a home-based intervention that

eliminated sugar-sweetened beverages showed

reduction in BMI scores

Recommended Community Strategies Strategies to encourage breastfeeding

Increase support for breastfeeding

--Evidence directly linking environmental

interventions that support breastfeeding with

obesity-related outcomes is lacking

--Epidemiologic studies indicate that breastfeeding

helps prevent pediatric obesity

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Require physical education in schools

--14 studies have demonstrated that school-based

PE was effective in increasing levels of physical

activity and improving physical fitness

--Minimum of 150 minwk in elementary schools

225 minwk in middle schools and high schools

throughout the school year as recommended by

NASPE

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Increase opportunities for extracurricular

physical activity

--Participation in after-school programs increased

studentsrsquo level of physical activity amp improved

obesity-related outcomes (improved CV fitness

reduced body fat)

--2 pilot studies providing extracurricular physical

activity showed increased levels of PA amp

decreased sedentary behavior

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Reduce screen time in public service venues

--A school-based RCT indicated that children who

reduced their television videotape amp video

game use had significant decrease in BMI tricep

skin fold thickness amp waist circumference

compared to controls

--Spending less time watching television is

associated with increased physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Improve access to outdoor recreational

facilities

--Review of 108 studies indicated that access to facilities

and programs for recreation near their homes amp time

spent outdoors correlated positively with increased

physical activity among childrenamp adults

--Perceptions that footpaths are safe for walking was

significantly associated with adults being classified as

physically active at a level sufficient for health benefits

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting

bicycling

--Longitudinal intervention studies have

demonstrated that improving bicycling

infrastructure is associated with increased

frequency of bicycling

--Cross-sectional studies indicated a significant

association between bicycling infrastructure amp

frequency of biking

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting walking

--Reviews of cross-sectional studies of

environmental correlates of physical activity amp

walking generally find a positive association

between infrastructure supportive of walking amp

physical activity

--Identifying amp creating safe routes to school

together with educational components

increased the number of students walking to

school

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Locating schools within easy walking

distance of residential areas

--Community-scale urban design amp land use policies amp

practices including locating schools stores workplaces

amp recreation areas close to residential areas are

effective in facilitating an increase in levels of physical

activity

--Majority of efforts to encourage walking to school involve

improving the routes rather than improving the location

of schools

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Improve access to public transportation

--Insufficient evidence exists to determine

effectiveness of transportation policies in

increasing the level of physical activity or

improving fitness

--1 study indicated that 29 of individuals who

walk to and from public transit achieve at least

30 minutes of daily physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Zone for mixed-use development

--Allows residential commercial institutional amp

other public land uses to be located in close

proximity to one another

--Studies using correlation analyses amp regression

models indicated that mixed land use was

associated with increased walking amp cycling

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance personal safety in areas where

persons are or could be physically active

--Cross-sectional studies have demonstrated a

negative relationship between crime rates andor

perceived safety amp physical activity in

neighborhoods

--Few intervention studies have evaluated the

impact of policies amp practices to improve

personal safety on physical activity

Geospatial Mapping Linking Urban

Environments to Health Risk

Measure association between environmental variables amp health risk factors

Assess relationships between variables at different levels of analysis

Used in conjunction with linear analyses

Our Community Environmental Model

of Obesity

Community Factors

Poverty

Crime

Grocery Quality

Restaurants

Parks

Sidewalks

Fast Food Outlets

Recreational

Facilities

Individual Factors

Dietary Intake

Physical Activity

Genetics

Family History

StressCoping

Eating Disorders

Psychological

Problems

Weight

Status

Chosen Neighborhoods

Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped

We then matched census-block groups within the income groups by population density and percentage of minority representation

One matched block group per income level was randomly selected

Prevalence of Obesity in

Block-Groups

0

5

10

15

20

25

30

35

40

45

50

Ag

e-a

dju

sted

Ob

esit

y P

rev

ale

nce

(

)

High-Income Low-Income

Age-standardized to the 1990 US Census

Density of Environmental Factors in the

Community Contributes to a ldquoToxicrdquo

Obesity Environment

0

2

4

6

8

10

12

14

16

18

Fast-food Convenience Store Bars

Den

sity

10

00

perso

ns

High-Income Low-Income

COMMUNITYrsquoS PERCEPTION OF SAFETY

0

5

10

15

20

25

30

35

40

Daytime Nighttime

Perc

en

t (

) F

eeli

ng

So

mew

hat

Safe

or

Un

safe

Low-Income High-Income

Percent Substandard (or worse) Housing

or Ground Conditions

of Residential Properties

0

10

20

30

Structural Grounds

Perc

en

t (

)

Low-Income High-Income

CONCLUSIONS

These data suggest that the higher

frequency of outlets providing

calorically-dense foods and alcohol may

contribute to greater obesity prevalence

in residents of low-income communities

More research is needed to thoroughly

document environmental determinants

of health and obesity

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

From 1994-1998 HUD randomly assigned

4498 women with children living in public

housing in high-poverty urban census

tracts to one of three groups (1) housing

vouchers redeemable only if they moved

to a low-poverty census tract (2)

unrestricted vouchers or (3) control group

(no vouchers)

Ludwig et al NEJM 201136516

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

10-12 year follow-up showed modest but

potentially important reductions in the

prevalence of extreme obesity amp diabetes in the

group moving from a neighborhood with high

poverty on one of low poverty compared to the

control group

No differences between the group receiving

traditional vouchers amp the control group

ldquoNeighborhoods matterrdquo

Ludwig et al NEJM 201136516

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance traffic safety in areas where

persons are or could be physically active

--Community-scale urban design amp land use policies to

promote physical activity including design components

to improve street lighting infrastructure projects to

increase safety of pedestrian street crossing and use of

traffic calming approaches such as speed humps amp

traffic circles are effective in increasing physical activity

--Both community-scale amp street-scale policies amp practices

are effective in increasing physical activity

Recommended Community Strategies Encourage Communities to Organize for Change

Participate in community coalitions or

partnerships to address obesity

--Little evidence is available to determine the

impact of community coalitions on obesity

prevention

--The presence of anti-smoking community

coalitions has been associated with lower rates

of tobacco consumption

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

$103 million awarded to 61 states and

communities including state amp local government

agencies tribes amp territories amp state amp local non-

profit organizations

To build capacity to implement changes for

community prevention efforts to ensure long-

term success

To implement evidence-based and practice-

based programs to improve health amp wellness

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Priority areas are

Tobacco-free living

Active living and healthy eating

Evidence-based quality clinical and other

preventive health services for prevention

and control of high blood pressure and

high cholesterol

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Applicants proposed specific activities in

line with their chosen priority areas in their

applications

Grantee activities will not be finalized until

plans are negotiated with CDC by early

2012

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Capacity-Building Award

The Confederated Tribes of The Chehalis

Reservation is receiving a $498663 planning

award to build capacity to support healthy

lifestyles among their tribal population of 1500

in Washington State

Work will target tobacco-free living active living

and healthy eating and quality clinical and other

healthy serviceswwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Implementation Award

Austin TX Dept of Health and Human Services

is receiving $1026158 to serve Travis County

(Austin) to expand efforts in tobacco-free living

active living and healthy eating quality clinical

and other preventive services social and

emotional wellness and healthy and safe

physical environmentswwwcdcgov1052011

Building sustainable healthy

communities Bottom line

Obesity is an environmental problem

Despite progress in genetic research public health advances only will occur when we take the environment seriously

Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment

Until we do this we will not make substantial progress in addressing the epidemic of obesity

Poston amp Foreyt Atherosclerosis 1999

Whatrsquos the best approach

Integrate all sectors of society into community

change interventions

Incorporate

Science amp Technology

Education

FamilyCommunity

Healthcare

Arts amp Entertainment

Law amp Politics

Commerce amp Trade

Sectors of Society

Arts amp Entertainm

ent

Commerce amp Trade

Education

FamilyCommunity

Healthcare

Law amp Politics

Science amp Technology

Project FIT rationale design and baseline characteristics of a school- and community-

based intervention to address physical activity and healthy eating among low-income

elementary school children

Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D

Oh HJ Orth J Randall S Mayfield K Holmes D

Source

Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu

Abstract

BACKGROUND

This paper describes Project FIT a collaboration between the public school system local

health systems physicians neighborhood associations businesses faith-based leaders

community agencies and university researchers to develop a multi-faceted approach to

promote physical activity and healthy eating toward the general goal of preventing and

reducing childhood obesity among children in Grand Rapids MI USA

METHODSDESIGN

There are four overall components to Project FIT school community social marketing and

school staff wellness - all that focus on 1) increasing access to safe and affordable physical

activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)

improving the affordability and availability of nutritious food in the neighborhoods surrounding

the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding

nutrition and physical activity among school staff parents and students 4) impacting the

culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging

dialogue among all community partners to leverage existing programs and introduce new

ones

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve availability of affordable healthier

food amp beverage choices in public service

venues

--Reducing the cost of healthier foods

increases their purchase

--Providing coupons redeemable for

healthier foods increases their purchase

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve geographic availability of

supermarkets in underserved areas

-- Greater access to nearby supermarkets is

associated with healthier eating behaviors

-- Increasing the number of supermarkets in

underserved neighborhoods increased

real estate values increased economic

activity amp employment amp resulted in lower

food prices

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Provide incentives to food retailers to locate in

andor offer healthier food choices in

underserved areas

-- Presence of retail venues that provide healthier

foods is associated with better nutrition

-- Greater availability of supermarkets was

associated with lower adolescent BMI scores

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Improve availability of mechanisms for

purchasing foods from farms

--Evidence supporting a direct link between

purchasing food from farms amp improved diet is

limited

--Two studies of initiatives to encourage

participation in farmersrsquo market showed

increased intention to eat more fruits amp

vegetables but no direct evidence

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Provide incentives for the production

distribution and procurement of foods from local

farms

--No evidence has been published to link local

food production amp health outcomes

--There is a current study exploring the potential

nutritional amp health benefits of eating locally

grown foods

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Restrict availability of less healthy foods amp

beverages in public service venues

--No peer-reviewed studies examined the impact

designed to restrict availability of less healthy

foods in public service venues

--21 states have policies that restrict the sale of

competitive foods in schools beyond USDA

regulations however no studies have evaluated

the impact of the policies

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Institute smaller portion size options in public

service venues

--Evidence is lacking to demonstrate effectiveness

of population-based interventions aimed at

reducing portion sizes in public service venues

--Evidence from clinical studies in laboratories

demonstrates decreasing portion sizes

decreases energy intake

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Limit advertisements of less healthy foods amp

beverages

--Little evidence is available regarding the impact

of restricting advertising on purchasing amp

consumption of less healthy foods

--Cross-sectional time-series studies of tobacco-

control efforts suggest an association between

advertising bans amp decreased tobacco

consumption

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Discourage consumption of sugar-sweetened

beverages

--One longitudinal study of a school-based

intervention among Native-American high school

students showed a substantial reduction in

sugar-sweetened beverages over a 3-year

period

--A RCT of a home-based intervention that

eliminated sugar-sweetened beverages showed

reduction in BMI scores

Recommended Community Strategies Strategies to encourage breastfeeding

Increase support for breastfeeding

--Evidence directly linking environmental

interventions that support breastfeeding with

obesity-related outcomes is lacking

--Epidemiologic studies indicate that breastfeeding

helps prevent pediatric obesity

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Require physical education in schools

--14 studies have demonstrated that school-based

PE was effective in increasing levels of physical

activity and improving physical fitness

--Minimum of 150 minwk in elementary schools

225 minwk in middle schools and high schools

throughout the school year as recommended by

NASPE

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Increase opportunities for extracurricular

physical activity

--Participation in after-school programs increased

studentsrsquo level of physical activity amp improved

obesity-related outcomes (improved CV fitness

reduced body fat)

--2 pilot studies providing extracurricular physical

activity showed increased levels of PA amp

decreased sedentary behavior

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Reduce screen time in public service venues

--A school-based RCT indicated that children who

reduced their television videotape amp video

game use had significant decrease in BMI tricep

skin fold thickness amp waist circumference

compared to controls

--Spending less time watching television is

associated with increased physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Improve access to outdoor recreational

facilities

--Review of 108 studies indicated that access to facilities

and programs for recreation near their homes amp time

spent outdoors correlated positively with increased

physical activity among childrenamp adults

--Perceptions that footpaths are safe for walking was

significantly associated with adults being classified as

physically active at a level sufficient for health benefits

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting

bicycling

--Longitudinal intervention studies have

demonstrated that improving bicycling

infrastructure is associated with increased

frequency of bicycling

--Cross-sectional studies indicated a significant

association between bicycling infrastructure amp

frequency of biking

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting walking

--Reviews of cross-sectional studies of

environmental correlates of physical activity amp

walking generally find a positive association

between infrastructure supportive of walking amp

physical activity

--Identifying amp creating safe routes to school

together with educational components

increased the number of students walking to

school

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Locating schools within easy walking

distance of residential areas

--Community-scale urban design amp land use policies amp

practices including locating schools stores workplaces

amp recreation areas close to residential areas are

effective in facilitating an increase in levels of physical

activity

--Majority of efforts to encourage walking to school involve

improving the routes rather than improving the location

of schools

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Improve access to public transportation

--Insufficient evidence exists to determine

effectiveness of transportation policies in

increasing the level of physical activity or

improving fitness

--1 study indicated that 29 of individuals who

walk to and from public transit achieve at least

30 minutes of daily physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Zone for mixed-use development

--Allows residential commercial institutional amp

other public land uses to be located in close

proximity to one another

--Studies using correlation analyses amp regression

models indicated that mixed land use was

associated with increased walking amp cycling

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance personal safety in areas where

persons are or could be physically active

--Cross-sectional studies have demonstrated a

negative relationship between crime rates andor

perceived safety amp physical activity in

neighborhoods

--Few intervention studies have evaluated the

impact of policies amp practices to improve

personal safety on physical activity

Geospatial Mapping Linking Urban

Environments to Health Risk

Measure association between environmental variables amp health risk factors

Assess relationships between variables at different levels of analysis

Used in conjunction with linear analyses

Our Community Environmental Model

of Obesity

Community Factors

Poverty

Crime

Grocery Quality

Restaurants

Parks

Sidewalks

Fast Food Outlets

Recreational

Facilities

Individual Factors

Dietary Intake

Physical Activity

Genetics

Family History

StressCoping

Eating Disorders

Psychological

Problems

Weight

Status

Chosen Neighborhoods

Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped

We then matched census-block groups within the income groups by population density and percentage of minority representation

One matched block group per income level was randomly selected

Prevalence of Obesity in

Block-Groups

0

5

10

15

20

25

30

35

40

45

50

Ag

e-a

dju

sted

Ob

esit

y P

rev

ale

nce

(

)

High-Income Low-Income

Age-standardized to the 1990 US Census

Density of Environmental Factors in the

Community Contributes to a ldquoToxicrdquo

Obesity Environment

0

2

4

6

8

10

12

14

16

18

Fast-food Convenience Store Bars

Den

sity

10

00

perso

ns

High-Income Low-Income

COMMUNITYrsquoS PERCEPTION OF SAFETY

0

5

10

15

20

25

30

35

40

Daytime Nighttime

Perc

en

t (

) F

eeli

ng

So

mew

hat

Safe

or

Un

safe

Low-Income High-Income

Percent Substandard (or worse) Housing

or Ground Conditions

of Residential Properties

0

10

20

30

Structural Grounds

Perc

en

t (

)

Low-Income High-Income

CONCLUSIONS

These data suggest that the higher

frequency of outlets providing

calorically-dense foods and alcohol may

contribute to greater obesity prevalence

in residents of low-income communities

More research is needed to thoroughly

document environmental determinants

of health and obesity

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

From 1994-1998 HUD randomly assigned

4498 women with children living in public

housing in high-poverty urban census

tracts to one of three groups (1) housing

vouchers redeemable only if they moved

to a low-poverty census tract (2)

unrestricted vouchers or (3) control group

(no vouchers)

Ludwig et al NEJM 201136516

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

10-12 year follow-up showed modest but

potentially important reductions in the

prevalence of extreme obesity amp diabetes in the

group moving from a neighborhood with high

poverty on one of low poverty compared to the

control group

No differences between the group receiving

traditional vouchers amp the control group

ldquoNeighborhoods matterrdquo

Ludwig et al NEJM 201136516

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance traffic safety in areas where

persons are or could be physically active

--Community-scale urban design amp land use policies to

promote physical activity including design components

to improve street lighting infrastructure projects to

increase safety of pedestrian street crossing and use of

traffic calming approaches such as speed humps amp

traffic circles are effective in increasing physical activity

--Both community-scale amp street-scale policies amp practices

are effective in increasing physical activity

Recommended Community Strategies Encourage Communities to Organize for Change

Participate in community coalitions or

partnerships to address obesity

--Little evidence is available to determine the

impact of community coalitions on obesity

prevention

--The presence of anti-smoking community

coalitions has been associated with lower rates

of tobacco consumption

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

$103 million awarded to 61 states and

communities including state amp local government

agencies tribes amp territories amp state amp local non-

profit organizations

To build capacity to implement changes for

community prevention efforts to ensure long-

term success

To implement evidence-based and practice-

based programs to improve health amp wellness

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Priority areas are

Tobacco-free living

Active living and healthy eating

Evidence-based quality clinical and other

preventive health services for prevention

and control of high blood pressure and

high cholesterol

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Applicants proposed specific activities in

line with their chosen priority areas in their

applications

Grantee activities will not be finalized until

plans are negotiated with CDC by early

2012

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Capacity-Building Award

The Confederated Tribes of The Chehalis

Reservation is receiving a $498663 planning

award to build capacity to support healthy

lifestyles among their tribal population of 1500

in Washington State

Work will target tobacco-free living active living

and healthy eating and quality clinical and other

healthy serviceswwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Implementation Award

Austin TX Dept of Health and Human Services

is receiving $1026158 to serve Travis County

(Austin) to expand efforts in tobacco-free living

active living and healthy eating quality clinical

and other preventive services social and

emotional wellness and healthy and safe

physical environmentswwwcdcgov1052011

Building sustainable healthy

communities Bottom line

Obesity is an environmental problem

Despite progress in genetic research public health advances only will occur when we take the environment seriously

Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment

Until we do this we will not make substantial progress in addressing the epidemic of obesity

Poston amp Foreyt Atherosclerosis 1999

Whatrsquos the best approach

Integrate all sectors of society into community

change interventions

Incorporate

Science amp Technology

Education

FamilyCommunity

Healthcare

Arts amp Entertainment

Law amp Politics

Commerce amp Trade

Sectors of Society

Arts amp Entertainm

ent

Commerce amp Trade

Education

FamilyCommunity

Healthcare

Law amp Politics

Science amp Technology

Project FIT rationale design and baseline characteristics of a school- and community-

based intervention to address physical activity and healthy eating among low-income

elementary school children

Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D

Oh HJ Orth J Randall S Mayfield K Holmes D

Source

Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu

Abstract

BACKGROUND

This paper describes Project FIT a collaboration between the public school system local

health systems physicians neighborhood associations businesses faith-based leaders

community agencies and university researchers to develop a multi-faceted approach to

promote physical activity and healthy eating toward the general goal of preventing and

reducing childhood obesity among children in Grand Rapids MI USA

METHODSDESIGN

There are four overall components to Project FIT school community social marketing and

school staff wellness - all that focus on 1) increasing access to safe and affordable physical

activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)

improving the affordability and availability of nutritious food in the neighborhoods surrounding

the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding

nutrition and physical activity among school staff parents and students 4) impacting the

culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging

dialogue among all community partners to leverage existing programs and introduce new

ones

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Improve geographic availability of

supermarkets in underserved areas

-- Greater access to nearby supermarkets is

associated with healthier eating behaviors

-- Increasing the number of supermarkets in

underserved neighborhoods increased

real estate values increased economic

activity amp employment amp resulted in lower

food prices

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Provide incentives to food retailers to locate in

andor offer healthier food choices in

underserved areas

-- Presence of retail venues that provide healthier

foods is associated with better nutrition

-- Greater availability of supermarkets was

associated with lower adolescent BMI scores

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Improve availability of mechanisms for

purchasing foods from farms

--Evidence supporting a direct link between

purchasing food from farms amp improved diet is

limited

--Two studies of initiatives to encourage

participation in farmersrsquo market showed

increased intention to eat more fruits amp

vegetables but no direct evidence

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Provide incentives for the production

distribution and procurement of foods from local

farms

--No evidence has been published to link local

food production amp health outcomes

--There is a current study exploring the potential

nutritional amp health benefits of eating locally

grown foods

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Restrict availability of less healthy foods amp

beverages in public service venues

--No peer-reviewed studies examined the impact

designed to restrict availability of less healthy

foods in public service venues

--21 states have policies that restrict the sale of

competitive foods in schools beyond USDA

regulations however no studies have evaluated

the impact of the policies

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Institute smaller portion size options in public

service venues

--Evidence is lacking to demonstrate effectiveness

of population-based interventions aimed at

reducing portion sizes in public service venues

--Evidence from clinical studies in laboratories

demonstrates decreasing portion sizes

decreases energy intake

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Limit advertisements of less healthy foods amp

beverages

--Little evidence is available regarding the impact

of restricting advertising on purchasing amp

consumption of less healthy foods

--Cross-sectional time-series studies of tobacco-

control efforts suggest an association between

advertising bans amp decreased tobacco

consumption

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Discourage consumption of sugar-sweetened

beverages

--One longitudinal study of a school-based

intervention among Native-American high school

students showed a substantial reduction in

sugar-sweetened beverages over a 3-year

period

--A RCT of a home-based intervention that

eliminated sugar-sweetened beverages showed

reduction in BMI scores

Recommended Community Strategies Strategies to encourage breastfeeding

Increase support for breastfeeding

--Evidence directly linking environmental

interventions that support breastfeeding with

obesity-related outcomes is lacking

--Epidemiologic studies indicate that breastfeeding

helps prevent pediatric obesity

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Require physical education in schools

--14 studies have demonstrated that school-based

PE was effective in increasing levels of physical

activity and improving physical fitness

--Minimum of 150 minwk in elementary schools

225 minwk in middle schools and high schools

throughout the school year as recommended by

NASPE

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Increase opportunities for extracurricular

physical activity

--Participation in after-school programs increased

studentsrsquo level of physical activity amp improved

obesity-related outcomes (improved CV fitness

reduced body fat)

--2 pilot studies providing extracurricular physical

activity showed increased levels of PA amp

decreased sedentary behavior

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Reduce screen time in public service venues

--A school-based RCT indicated that children who

reduced their television videotape amp video

game use had significant decrease in BMI tricep

skin fold thickness amp waist circumference

compared to controls

--Spending less time watching television is

associated with increased physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Improve access to outdoor recreational

facilities

--Review of 108 studies indicated that access to facilities

and programs for recreation near their homes amp time

spent outdoors correlated positively with increased

physical activity among childrenamp adults

--Perceptions that footpaths are safe for walking was

significantly associated with adults being classified as

physically active at a level sufficient for health benefits

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting

bicycling

--Longitudinal intervention studies have

demonstrated that improving bicycling

infrastructure is associated with increased

frequency of bicycling

--Cross-sectional studies indicated a significant

association between bicycling infrastructure amp

frequency of biking

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting walking

--Reviews of cross-sectional studies of

environmental correlates of physical activity amp

walking generally find a positive association

between infrastructure supportive of walking amp

physical activity

--Identifying amp creating safe routes to school

together with educational components

increased the number of students walking to

school

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Locating schools within easy walking

distance of residential areas

--Community-scale urban design amp land use policies amp

practices including locating schools stores workplaces

amp recreation areas close to residential areas are

effective in facilitating an increase in levels of physical

activity

--Majority of efforts to encourage walking to school involve

improving the routes rather than improving the location

of schools

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Improve access to public transportation

--Insufficient evidence exists to determine

effectiveness of transportation policies in

increasing the level of physical activity or

improving fitness

--1 study indicated that 29 of individuals who

walk to and from public transit achieve at least

30 minutes of daily physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Zone for mixed-use development

--Allows residential commercial institutional amp

other public land uses to be located in close

proximity to one another

--Studies using correlation analyses amp regression

models indicated that mixed land use was

associated with increased walking amp cycling

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance personal safety in areas where

persons are or could be physically active

--Cross-sectional studies have demonstrated a

negative relationship between crime rates andor

perceived safety amp physical activity in

neighborhoods

--Few intervention studies have evaluated the

impact of policies amp practices to improve

personal safety on physical activity

Geospatial Mapping Linking Urban

Environments to Health Risk

Measure association between environmental variables amp health risk factors

Assess relationships between variables at different levels of analysis

Used in conjunction with linear analyses

Our Community Environmental Model

of Obesity

Community Factors

Poverty

Crime

Grocery Quality

Restaurants

Parks

Sidewalks

Fast Food Outlets

Recreational

Facilities

Individual Factors

Dietary Intake

Physical Activity

Genetics

Family History

StressCoping

Eating Disorders

Psychological

Problems

Weight

Status

Chosen Neighborhoods

Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped

We then matched census-block groups within the income groups by population density and percentage of minority representation

One matched block group per income level was randomly selected

Prevalence of Obesity in

Block-Groups

0

5

10

15

20

25

30

35

40

45

50

Ag

e-a

dju

sted

Ob

esit

y P

rev

ale

nce

(

)

High-Income Low-Income

Age-standardized to the 1990 US Census

Density of Environmental Factors in the

Community Contributes to a ldquoToxicrdquo

Obesity Environment

0

2

4

6

8

10

12

14

16

18

Fast-food Convenience Store Bars

Den

sity

10

00

perso

ns

High-Income Low-Income

COMMUNITYrsquoS PERCEPTION OF SAFETY

0

5

10

15

20

25

30

35

40

Daytime Nighttime

Perc

en

t (

) F

eeli

ng

So

mew

hat

Safe

or

Un

safe

Low-Income High-Income

Percent Substandard (or worse) Housing

or Ground Conditions

of Residential Properties

0

10

20

30

Structural Grounds

Perc

en

t (

)

Low-Income High-Income

CONCLUSIONS

These data suggest that the higher

frequency of outlets providing

calorically-dense foods and alcohol may

contribute to greater obesity prevalence

in residents of low-income communities

More research is needed to thoroughly

document environmental determinants

of health and obesity

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

From 1994-1998 HUD randomly assigned

4498 women with children living in public

housing in high-poverty urban census

tracts to one of three groups (1) housing

vouchers redeemable only if they moved

to a low-poverty census tract (2)

unrestricted vouchers or (3) control group

(no vouchers)

Ludwig et al NEJM 201136516

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

10-12 year follow-up showed modest but

potentially important reductions in the

prevalence of extreme obesity amp diabetes in the

group moving from a neighborhood with high

poverty on one of low poverty compared to the

control group

No differences between the group receiving

traditional vouchers amp the control group

ldquoNeighborhoods matterrdquo

Ludwig et al NEJM 201136516

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance traffic safety in areas where

persons are or could be physically active

--Community-scale urban design amp land use policies to

promote physical activity including design components

to improve street lighting infrastructure projects to

increase safety of pedestrian street crossing and use of

traffic calming approaches such as speed humps amp

traffic circles are effective in increasing physical activity

--Both community-scale amp street-scale policies amp practices

are effective in increasing physical activity

Recommended Community Strategies Encourage Communities to Organize for Change

Participate in community coalitions or

partnerships to address obesity

--Little evidence is available to determine the

impact of community coalitions on obesity

prevention

--The presence of anti-smoking community

coalitions has been associated with lower rates

of tobacco consumption

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

$103 million awarded to 61 states and

communities including state amp local government

agencies tribes amp territories amp state amp local non-

profit organizations

To build capacity to implement changes for

community prevention efforts to ensure long-

term success

To implement evidence-based and practice-

based programs to improve health amp wellness

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Priority areas are

Tobacco-free living

Active living and healthy eating

Evidence-based quality clinical and other

preventive health services for prevention

and control of high blood pressure and

high cholesterol

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Applicants proposed specific activities in

line with their chosen priority areas in their

applications

Grantee activities will not be finalized until

plans are negotiated with CDC by early

2012

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Capacity-Building Award

The Confederated Tribes of The Chehalis

Reservation is receiving a $498663 planning

award to build capacity to support healthy

lifestyles among their tribal population of 1500

in Washington State

Work will target tobacco-free living active living

and healthy eating and quality clinical and other

healthy serviceswwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Implementation Award

Austin TX Dept of Health and Human Services

is receiving $1026158 to serve Travis County

(Austin) to expand efforts in tobacco-free living

active living and healthy eating quality clinical

and other preventive services social and

emotional wellness and healthy and safe

physical environmentswwwcdcgov1052011

Building sustainable healthy

communities Bottom line

Obesity is an environmental problem

Despite progress in genetic research public health advances only will occur when we take the environment seriously

Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment

Until we do this we will not make substantial progress in addressing the epidemic of obesity

Poston amp Foreyt Atherosclerosis 1999

Whatrsquos the best approach

Integrate all sectors of society into community

change interventions

Incorporate

Science amp Technology

Education

FamilyCommunity

Healthcare

Arts amp Entertainment

Law amp Politics

Commerce amp Trade

Sectors of Society

Arts amp Entertainm

ent

Commerce amp Trade

Education

FamilyCommunity

Healthcare

Law amp Politics

Science amp Technology

Project FIT rationale design and baseline characteristics of a school- and community-

based intervention to address physical activity and healthy eating among low-income

elementary school children

Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D

Oh HJ Orth J Randall S Mayfield K Holmes D

Source

Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu

Abstract

BACKGROUND

This paper describes Project FIT a collaboration between the public school system local

health systems physicians neighborhood associations businesses faith-based leaders

community agencies and university researchers to develop a multi-faceted approach to

promote physical activity and healthy eating toward the general goal of preventing and

reducing childhood obesity among children in Grand Rapids MI USA

METHODSDESIGN

There are four overall components to Project FIT school community social marketing and

school staff wellness - all that focus on 1) increasing access to safe and affordable physical

activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)

improving the affordability and availability of nutritious food in the neighborhoods surrounding

the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding

nutrition and physical activity among school staff parents and students 4) impacting the

culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging

dialogue among all community partners to leverage existing programs and introduce new

ones

Recommended Community Strategies Strategies to Promote the Availability of Affordable

Healthy Food and Beverages

Provide incentives to food retailers to locate in

andor offer healthier food choices in

underserved areas

-- Presence of retail venues that provide healthier

foods is associated with better nutrition

-- Greater availability of supermarkets was

associated with lower adolescent BMI scores

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Improve availability of mechanisms for

purchasing foods from farms

--Evidence supporting a direct link between

purchasing food from farms amp improved diet is

limited

--Two studies of initiatives to encourage

participation in farmersrsquo market showed

increased intention to eat more fruits amp

vegetables but no direct evidence

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Provide incentives for the production

distribution and procurement of foods from local

farms

--No evidence has been published to link local

food production amp health outcomes

--There is a current study exploring the potential

nutritional amp health benefits of eating locally

grown foods

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Restrict availability of less healthy foods amp

beverages in public service venues

--No peer-reviewed studies examined the impact

designed to restrict availability of less healthy

foods in public service venues

--21 states have policies that restrict the sale of

competitive foods in schools beyond USDA

regulations however no studies have evaluated

the impact of the policies

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Institute smaller portion size options in public

service venues

--Evidence is lacking to demonstrate effectiveness

of population-based interventions aimed at

reducing portion sizes in public service venues

--Evidence from clinical studies in laboratories

demonstrates decreasing portion sizes

decreases energy intake

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Limit advertisements of less healthy foods amp

beverages

--Little evidence is available regarding the impact

of restricting advertising on purchasing amp

consumption of less healthy foods

--Cross-sectional time-series studies of tobacco-

control efforts suggest an association between

advertising bans amp decreased tobacco

consumption

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Discourage consumption of sugar-sweetened

beverages

--One longitudinal study of a school-based

intervention among Native-American high school

students showed a substantial reduction in

sugar-sweetened beverages over a 3-year

period

--A RCT of a home-based intervention that

eliminated sugar-sweetened beverages showed

reduction in BMI scores

Recommended Community Strategies Strategies to encourage breastfeeding

Increase support for breastfeeding

--Evidence directly linking environmental

interventions that support breastfeeding with

obesity-related outcomes is lacking

--Epidemiologic studies indicate that breastfeeding

helps prevent pediatric obesity

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Require physical education in schools

--14 studies have demonstrated that school-based

PE was effective in increasing levels of physical

activity and improving physical fitness

--Minimum of 150 minwk in elementary schools

225 minwk in middle schools and high schools

throughout the school year as recommended by

NASPE

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Increase opportunities for extracurricular

physical activity

--Participation in after-school programs increased

studentsrsquo level of physical activity amp improved

obesity-related outcomes (improved CV fitness

reduced body fat)

--2 pilot studies providing extracurricular physical

activity showed increased levels of PA amp

decreased sedentary behavior

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Reduce screen time in public service venues

--A school-based RCT indicated that children who

reduced their television videotape amp video

game use had significant decrease in BMI tricep

skin fold thickness amp waist circumference

compared to controls

--Spending less time watching television is

associated with increased physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Improve access to outdoor recreational

facilities

--Review of 108 studies indicated that access to facilities

and programs for recreation near their homes amp time

spent outdoors correlated positively with increased

physical activity among childrenamp adults

--Perceptions that footpaths are safe for walking was

significantly associated with adults being classified as

physically active at a level sufficient for health benefits

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting

bicycling

--Longitudinal intervention studies have

demonstrated that improving bicycling

infrastructure is associated with increased

frequency of bicycling

--Cross-sectional studies indicated a significant

association between bicycling infrastructure amp

frequency of biking

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting walking

--Reviews of cross-sectional studies of

environmental correlates of physical activity amp

walking generally find a positive association

between infrastructure supportive of walking amp

physical activity

--Identifying amp creating safe routes to school

together with educational components

increased the number of students walking to

school

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Locating schools within easy walking

distance of residential areas

--Community-scale urban design amp land use policies amp

practices including locating schools stores workplaces

amp recreation areas close to residential areas are

effective in facilitating an increase in levels of physical

activity

--Majority of efforts to encourage walking to school involve

improving the routes rather than improving the location

of schools

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Improve access to public transportation

--Insufficient evidence exists to determine

effectiveness of transportation policies in

increasing the level of physical activity or

improving fitness

--1 study indicated that 29 of individuals who

walk to and from public transit achieve at least

30 minutes of daily physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Zone for mixed-use development

--Allows residential commercial institutional amp

other public land uses to be located in close

proximity to one another

--Studies using correlation analyses amp regression

models indicated that mixed land use was

associated with increased walking amp cycling

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance personal safety in areas where

persons are or could be physically active

--Cross-sectional studies have demonstrated a

negative relationship between crime rates andor

perceived safety amp physical activity in

neighborhoods

--Few intervention studies have evaluated the

impact of policies amp practices to improve

personal safety on physical activity

Geospatial Mapping Linking Urban

Environments to Health Risk

Measure association between environmental variables amp health risk factors

Assess relationships between variables at different levels of analysis

Used in conjunction with linear analyses

Our Community Environmental Model

of Obesity

Community Factors

Poverty

Crime

Grocery Quality

Restaurants

Parks

Sidewalks

Fast Food Outlets

Recreational

Facilities

Individual Factors

Dietary Intake

Physical Activity

Genetics

Family History

StressCoping

Eating Disorders

Psychological

Problems

Weight

Status

Chosen Neighborhoods

Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped

We then matched census-block groups within the income groups by population density and percentage of minority representation

One matched block group per income level was randomly selected

Prevalence of Obesity in

Block-Groups

0

5

10

15

20

25

30

35

40

45

50

Ag

e-a

dju

sted

Ob

esit

y P

rev

ale

nce

(

)

High-Income Low-Income

Age-standardized to the 1990 US Census

Density of Environmental Factors in the

Community Contributes to a ldquoToxicrdquo

Obesity Environment

0

2

4

6

8

10

12

14

16

18

Fast-food Convenience Store Bars

Den

sity

10

00

perso

ns

High-Income Low-Income

COMMUNITYrsquoS PERCEPTION OF SAFETY

0

5

10

15

20

25

30

35

40

Daytime Nighttime

Perc

en

t (

) F

eeli

ng

So

mew

hat

Safe

or

Un

safe

Low-Income High-Income

Percent Substandard (or worse) Housing

or Ground Conditions

of Residential Properties

0

10

20

30

Structural Grounds

Perc

en

t (

)

Low-Income High-Income

CONCLUSIONS

These data suggest that the higher

frequency of outlets providing

calorically-dense foods and alcohol may

contribute to greater obesity prevalence

in residents of low-income communities

More research is needed to thoroughly

document environmental determinants

of health and obesity

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

From 1994-1998 HUD randomly assigned

4498 women with children living in public

housing in high-poverty urban census

tracts to one of three groups (1) housing

vouchers redeemable only if they moved

to a low-poverty census tract (2)

unrestricted vouchers or (3) control group

(no vouchers)

Ludwig et al NEJM 201136516

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

10-12 year follow-up showed modest but

potentially important reductions in the

prevalence of extreme obesity amp diabetes in the

group moving from a neighborhood with high

poverty on one of low poverty compared to the

control group

No differences between the group receiving

traditional vouchers amp the control group

ldquoNeighborhoods matterrdquo

Ludwig et al NEJM 201136516

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance traffic safety in areas where

persons are or could be physically active

--Community-scale urban design amp land use policies to

promote physical activity including design components

to improve street lighting infrastructure projects to

increase safety of pedestrian street crossing and use of

traffic calming approaches such as speed humps amp

traffic circles are effective in increasing physical activity

--Both community-scale amp street-scale policies amp practices

are effective in increasing physical activity

Recommended Community Strategies Encourage Communities to Organize for Change

Participate in community coalitions or

partnerships to address obesity

--Little evidence is available to determine the

impact of community coalitions on obesity

prevention

--The presence of anti-smoking community

coalitions has been associated with lower rates

of tobacco consumption

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

$103 million awarded to 61 states and

communities including state amp local government

agencies tribes amp territories amp state amp local non-

profit organizations

To build capacity to implement changes for

community prevention efforts to ensure long-

term success

To implement evidence-based and practice-

based programs to improve health amp wellness

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Priority areas are

Tobacco-free living

Active living and healthy eating

Evidence-based quality clinical and other

preventive health services for prevention

and control of high blood pressure and

high cholesterol

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Applicants proposed specific activities in

line with their chosen priority areas in their

applications

Grantee activities will not be finalized until

plans are negotiated with CDC by early

2012

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Capacity-Building Award

The Confederated Tribes of The Chehalis

Reservation is receiving a $498663 planning

award to build capacity to support healthy

lifestyles among their tribal population of 1500

in Washington State

Work will target tobacco-free living active living

and healthy eating and quality clinical and other

healthy serviceswwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Implementation Award

Austin TX Dept of Health and Human Services

is receiving $1026158 to serve Travis County

(Austin) to expand efforts in tobacco-free living

active living and healthy eating quality clinical

and other preventive services social and

emotional wellness and healthy and safe

physical environmentswwwcdcgov1052011

Building sustainable healthy

communities Bottom line

Obesity is an environmental problem

Despite progress in genetic research public health advances only will occur when we take the environment seriously

Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment

Until we do this we will not make substantial progress in addressing the epidemic of obesity

Poston amp Foreyt Atherosclerosis 1999

Whatrsquos the best approach

Integrate all sectors of society into community

change interventions

Incorporate

Science amp Technology

Education

FamilyCommunity

Healthcare

Arts amp Entertainment

Law amp Politics

Commerce amp Trade

Sectors of Society

Arts amp Entertainm

ent

Commerce amp Trade

Education

FamilyCommunity

Healthcare

Law amp Politics

Science amp Technology

Project FIT rationale design and baseline characteristics of a school- and community-

based intervention to address physical activity and healthy eating among low-income

elementary school children

Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D

Oh HJ Orth J Randall S Mayfield K Holmes D

Source

Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu

Abstract

BACKGROUND

This paper describes Project FIT a collaboration between the public school system local

health systems physicians neighborhood associations businesses faith-based leaders

community agencies and university researchers to develop a multi-faceted approach to

promote physical activity and healthy eating toward the general goal of preventing and

reducing childhood obesity among children in Grand Rapids MI USA

METHODSDESIGN

There are four overall components to Project FIT school community social marketing and

school staff wellness - all that focus on 1) increasing access to safe and affordable physical

activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)

improving the affordability and availability of nutritious food in the neighborhoods surrounding

the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding

nutrition and physical activity among school staff parents and students 4) impacting the

culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging

dialogue among all community partners to leverage existing programs and introduce new

ones

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Improve availability of mechanisms for

purchasing foods from farms

--Evidence supporting a direct link between

purchasing food from farms amp improved diet is

limited

--Two studies of initiatives to encourage

participation in farmersrsquo market showed

increased intention to eat more fruits amp

vegetables but no direct evidence

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Provide incentives for the production

distribution and procurement of foods from local

farms

--No evidence has been published to link local

food production amp health outcomes

--There is a current study exploring the potential

nutritional amp health benefits of eating locally

grown foods

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Restrict availability of less healthy foods amp

beverages in public service venues

--No peer-reviewed studies examined the impact

designed to restrict availability of less healthy

foods in public service venues

--21 states have policies that restrict the sale of

competitive foods in schools beyond USDA

regulations however no studies have evaluated

the impact of the policies

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Institute smaller portion size options in public

service venues

--Evidence is lacking to demonstrate effectiveness

of population-based interventions aimed at

reducing portion sizes in public service venues

--Evidence from clinical studies in laboratories

demonstrates decreasing portion sizes

decreases energy intake

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Limit advertisements of less healthy foods amp

beverages

--Little evidence is available regarding the impact

of restricting advertising on purchasing amp

consumption of less healthy foods

--Cross-sectional time-series studies of tobacco-

control efforts suggest an association between

advertising bans amp decreased tobacco

consumption

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Discourage consumption of sugar-sweetened

beverages

--One longitudinal study of a school-based

intervention among Native-American high school

students showed a substantial reduction in

sugar-sweetened beverages over a 3-year

period

--A RCT of a home-based intervention that

eliminated sugar-sweetened beverages showed

reduction in BMI scores

Recommended Community Strategies Strategies to encourage breastfeeding

Increase support for breastfeeding

--Evidence directly linking environmental

interventions that support breastfeeding with

obesity-related outcomes is lacking

--Epidemiologic studies indicate that breastfeeding

helps prevent pediatric obesity

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Require physical education in schools

--14 studies have demonstrated that school-based

PE was effective in increasing levels of physical

activity and improving physical fitness

--Minimum of 150 minwk in elementary schools

225 minwk in middle schools and high schools

throughout the school year as recommended by

NASPE

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Increase opportunities for extracurricular

physical activity

--Participation in after-school programs increased

studentsrsquo level of physical activity amp improved

obesity-related outcomes (improved CV fitness

reduced body fat)

--2 pilot studies providing extracurricular physical

activity showed increased levels of PA amp

decreased sedentary behavior

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Reduce screen time in public service venues

--A school-based RCT indicated that children who

reduced their television videotape amp video

game use had significant decrease in BMI tricep

skin fold thickness amp waist circumference

compared to controls

--Spending less time watching television is

associated with increased physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Improve access to outdoor recreational

facilities

--Review of 108 studies indicated that access to facilities

and programs for recreation near their homes amp time

spent outdoors correlated positively with increased

physical activity among childrenamp adults

--Perceptions that footpaths are safe for walking was

significantly associated with adults being classified as

physically active at a level sufficient for health benefits

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting

bicycling

--Longitudinal intervention studies have

demonstrated that improving bicycling

infrastructure is associated with increased

frequency of bicycling

--Cross-sectional studies indicated a significant

association between bicycling infrastructure amp

frequency of biking

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting walking

--Reviews of cross-sectional studies of

environmental correlates of physical activity amp

walking generally find a positive association

between infrastructure supportive of walking amp

physical activity

--Identifying amp creating safe routes to school

together with educational components

increased the number of students walking to

school

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Locating schools within easy walking

distance of residential areas

--Community-scale urban design amp land use policies amp

practices including locating schools stores workplaces

amp recreation areas close to residential areas are

effective in facilitating an increase in levels of physical

activity

--Majority of efforts to encourage walking to school involve

improving the routes rather than improving the location

of schools

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Improve access to public transportation

--Insufficient evidence exists to determine

effectiveness of transportation policies in

increasing the level of physical activity or

improving fitness

--1 study indicated that 29 of individuals who

walk to and from public transit achieve at least

30 minutes of daily physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Zone for mixed-use development

--Allows residential commercial institutional amp

other public land uses to be located in close

proximity to one another

--Studies using correlation analyses amp regression

models indicated that mixed land use was

associated with increased walking amp cycling

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance personal safety in areas where

persons are or could be physically active

--Cross-sectional studies have demonstrated a

negative relationship between crime rates andor

perceived safety amp physical activity in

neighborhoods

--Few intervention studies have evaluated the

impact of policies amp practices to improve

personal safety on physical activity

Geospatial Mapping Linking Urban

Environments to Health Risk

Measure association between environmental variables amp health risk factors

Assess relationships between variables at different levels of analysis

Used in conjunction with linear analyses

Our Community Environmental Model

of Obesity

Community Factors

Poverty

Crime

Grocery Quality

Restaurants

Parks

Sidewalks

Fast Food Outlets

Recreational

Facilities

Individual Factors

Dietary Intake

Physical Activity

Genetics

Family History

StressCoping

Eating Disorders

Psychological

Problems

Weight

Status

Chosen Neighborhoods

Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped

We then matched census-block groups within the income groups by population density and percentage of minority representation

One matched block group per income level was randomly selected

Prevalence of Obesity in

Block-Groups

0

5

10

15

20

25

30

35

40

45

50

Ag

e-a

dju

sted

Ob

esit

y P

rev

ale

nce

(

)

High-Income Low-Income

Age-standardized to the 1990 US Census

Density of Environmental Factors in the

Community Contributes to a ldquoToxicrdquo

Obesity Environment

0

2

4

6

8

10

12

14

16

18

Fast-food Convenience Store Bars

Den

sity

10

00

perso

ns

High-Income Low-Income

COMMUNITYrsquoS PERCEPTION OF SAFETY

0

5

10

15

20

25

30

35

40

Daytime Nighttime

Perc

en

t (

) F

eeli

ng

So

mew

hat

Safe

or

Un

safe

Low-Income High-Income

Percent Substandard (or worse) Housing

or Ground Conditions

of Residential Properties

0

10

20

30

Structural Grounds

Perc

en

t (

)

Low-Income High-Income

CONCLUSIONS

These data suggest that the higher

frequency of outlets providing

calorically-dense foods and alcohol may

contribute to greater obesity prevalence

in residents of low-income communities

More research is needed to thoroughly

document environmental determinants

of health and obesity

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

From 1994-1998 HUD randomly assigned

4498 women with children living in public

housing in high-poverty urban census

tracts to one of three groups (1) housing

vouchers redeemable only if they moved

to a low-poverty census tract (2)

unrestricted vouchers or (3) control group

(no vouchers)

Ludwig et al NEJM 201136516

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

10-12 year follow-up showed modest but

potentially important reductions in the

prevalence of extreme obesity amp diabetes in the

group moving from a neighborhood with high

poverty on one of low poverty compared to the

control group

No differences between the group receiving

traditional vouchers amp the control group

ldquoNeighborhoods matterrdquo

Ludwig et al NEJM 201136516

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance traffic safety in areas where

persons are or could be physically active

--Community-scale urban design amp land use policies to

promote physical activity including design components

to improve street lighting infrastructure projects to

increase safety of pedestrian street crossing and use of

traffic calming approaches such as speed humps amp

traffic circles are effective in increasing physical activity

--Both community-scale amp street-scale policies amp practices

are effective in increasing physical activity

Recommended Community Strategies Encourage Communities to Organize for Change

Participate in community coalitions or

partnerships to address obesity

--Little evidence is available to determine the

impact of community coalitions on obesity

prevention

--The presence of anti-smoking community

coalitions has been associated with lower rates

of tobacco consumption

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

$103 million awarded to 61 states and

communities including state amp local government

agencies tribes amp territories amp state amp local non-

profit organizations

To build capacity to implement changes for

community prevention efforts to ensure long-

term success

To implement evidence-based and practice-

based programs to improve health amp wellness

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Priority areas are

Tobacco-free living

Active living and healthy eating

Evidence-based quality clinical and other

preventive health services for prevention

and control of high blood pressure and

high cholesterol

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Applicants proposed specific activities in

line with their chosen priority areas in their

applications

Grantee activities will not be finalized until

plans are negotiated with CDC by early

2012

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Capacity-Building Award

The Confederated Tribes of The Chehalis

Reservation is receiving a $498663 planning

award to build capacity to support healthy

lifestyles among their tribal population of 1500

in Washington State

Work will target tobacco-free living active living

and healthy eating and quality clinical and other

healthy serviceswwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Implementation Award

Austin TX Dept of Health and Human Services

is receiving $1026158 to serve Travis County

(Austin) to expand efforts in tobacco-free living

active living and healthy eating quality clinical

and other preventive services social and

emotional wellness and healthy and safe

physical environmentswwwcdcgov1052011

Building sustainable healthy

communities Bottom line

Obesity is an environmental problem

Despite progress in genetic research public health advances only will occur when we take the environment seriously

Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment

Until we do this we will not make substantial progress in addressing the epidemic of obesity

Poston amp Foreyt Atherosclerosis 1999

Whatrsquos the best approach

Integrate all sectors of society into community

change interventions

Incorporate

Science amp Technology

Education

FamilyCommunity

Healthcare

Arts amp Entertainment

Law amp Politics

Commerce amp Trade

Sectors of Society

Arts amp Entertainm

ent

Commerce amp Trade

Education

FamilyCommunity

Healthcare

Law amp Politics

Science amp Technology

Project FIT rationale design and baseline characteristics of a school- and community-

based intervention to address physical activity and healthy eating among low-income

elementary school children

Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D

Oh HJ Orth J Randall S Mayfield K Holmes D

Source

Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu

Abstract

BACKGROUND

This paper describes Project FIT a collaboration between the public school system local

health systems physicians neighborhood associations businesses faith-based leaders

community agencies and university researchers to develop a multi-faceted approach to

promote physical activity and healthy eating toward the general goal of preventing and

reducing childhood obesity among children in Grand Rapids MI USA

METHODSDESIGN

There are four overall components to Project FIT school community social marketing and

school staff wellness - all that focus on 1) increasing access to safe and affordable physical

activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)

improving the affordability and availability of nutritious food in the neighborhoods surrounding

the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding

nutrition and physical activity among school staff parents and students 4) impacting the

culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging

dialogue among all community partners to leverage existing programs and introduce new

ones

Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy

Food and Beverages

Provide incentives for the production

distribution and procurement of foods from local

farms

--No evidence has been published to link local

food production amp health outcomes

--There is a current study exploring the potential

nutritional amp health benefits of eating locally

grown foods

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Restrict availability of less healthy foods amp

beverages in public service venues

--No peer-reviewed studies examined the impact

designed to restrict availability of less healthy

foods in public service venues

--21 states have policies that restrict the sale of

competitive foods in schools beyond USDA

regulations however no studies have evaluated

the impact of the policies

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Institute smaller portion size options in public

service venues

--Evidence is lacking to demonstrate effectiveness

of population-based interventions aimed at

reducing portion sizes in public service venues

--Evidence from clinical studies in laboratories

demonstrates decreasing portion sizes

decreases energy intake

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Limit advertisements of less healthy foods amp

beverages

--Little evidence is available regarding the impact

of restricting advertising on purchasing amp

consumption of less healthy foods

--Cross-sectional time-series studies of tobacco-

control efforts suggest an association between

advertising bans amp decreased tobacco

consumption

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Discourage consumption of sugar-sweetened

beverages

--One longitudinal study of a school-based

intervention among Native-American high school

students showed a substantial reduction in

sugar-sweetened beverages over a 3-year

period

--A RCT of a home-based intervention that

eliminated sugar-sweetened beverages showed

reduction in BMI scores

Recommended Community Strategies Strategies to encourage breastfeeding

Increase support for breastfeeding

--Evidence directly linking environmental

interventions that support breastfeeding with

obesity-related outcomes is lacking

--Epidemiologic studies indicate that breastfeeding

helps prevent pediatric obesity

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Require physical education in schools

--14 studies have demonstrated that school-based

PE was effective in increasing levels of physical

activity and improving physical fitness

--Minimum of 150 minwk in elementary schools

225 minwk in middle schools and high schools

throughout the school year as recommended by

NASPE

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Increase opportunities for extracurricular

physical activity

--Participation in after-school programs increased

studentsrsquo level of physical activity amp improved

obesity-related outcomes (improved CV fitness

reduced body fat)

--2 pilot studies providing extracurricular physical

activity showed increased levels of PA amp

decreased sedentary behavior

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Reduce screen time in public service venues

--A school-based RCT indicated that children who

reduced their television videotape amp video

game use had significant decrease in BMI tricep

skin fold thickness amp waist circumference

compared to controls

--Spending less time watching television is

associated with increased physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Improve access to outdoor recreational

facilities

--Review of 108 studies indicated that access to facilities

and programs for recreation near their homes amp time

spent outdoors correlated positively with increased

physical activity among childrenamp adults

--Perceptions that footpaths are safe for walking was

significantly associated with adults being classified as

physically active at a level sufficient for health benefits

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting

bicycling

--Longitudinal intervention studies have

demonstrated that improving bicycling

infrastructure is associated with increased

frequency of bicycling

--Cross-sectional studies indicated a significant

association between bicycling infrastructure amp

frequency of biking

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting walking

--Reviews of cross-sectional studies of

environmental correlates of physical activity amp

walking generally find a positive association

between infrastructure supportive of walking amp

physical activity

--Identifying amp creating safe routes to school

together with educational components

increased the number of students walking to

school

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Locating schools within easy walking

distance of residential areas

--Community-scale urban design amp land use policies amp

practices including locating schools stores workplaces

amp recreation areas close to residential areas are

effective in facilitating an increase in levels of physical

activity

--Majority of efforts to encourage walking to school involve

improving the routes rather than improving the location

of schools

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Improve access to public transportation

--Insufficient evidence exists to determine

effectiveness of transportation policies in

increasing the level of physical activity or

improving fitness

--1 study indicated that 29 of individuals who

walk to and from public transit achieve at least

30 minutes of daily physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Zone for mixed-use development

--Allows residential commercial institutional amp

other public land uses to be located in close

proximity to one another

--Studies using correlation analyses amp regression

models indicated that mixed land use was

associated with increased walking amp cycling

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance personal safety in areas where

persons are or could be physically active

--Cross-sectional studies have demonstrated a

negative relationship between crime rates andor

perceived safety amp physical activity in

neighborhoods

--Few intervention studies have evaluated the

impact of policies amp practices to improve

personal safety on physical activity

Geospatial Mapping Linking Urban

Environments to Health Risk

Measure association between environmental variables amp health risk factors

Assess relationships between variables at different levels of analysis

Used in conjunction with linear analyses

Our Community Environmental Model

of Obesity

Community Factors

Poverty

Crime

Grocery Quality

Restaurants

Parks

Sidewalks

Fast Food Outlets

Recreational

Facilities

Individual Factors

Dietary Intake

Physical Activity

Genetics

Family History

StressCoping

Eating Disorders

Psychological

Problems

Weight

Status

Chosen Neighborhoods

Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped

We then matched census-block groups within the income groups by population density and percentage of minority representation

One matched block group per income level was randomly selected

Prevalence of Obesity in

Block-Groups

0

5

10

15

20

25

30

35

40

45

50

Ag

e-a

dju

sted

Ob

esit

y P

rev

ale

nce

(

)

High-Income Low-Income

Age-standardized to the 1990 US Census

Density of Environmental Factors in the

Community Contributes to a ldquoToxicrdquo

Obesity Environment

0

2

4

6

8

10

12

14

16

18

Fast-food Convenience Store Bars

Den

sity

10

00

perso

ns

High-Income Low-Income

COMMUNITYrsquoS PERCEPTION OF SAFETY

0

5

10

15

20

25

30

35

40

Daytime Nighttime

Perc

en

t (

) F

eeli

ng

So

mew

hat

Safe

or

Un

safe

Low-Income High-Income

Percent Substandard (or worse) Housing

or Ground Conditions

of Residential Properties

0

10

20

30

Structural Grounds

Perc

en

t (

)

Low-Income High-Income

CONCLUSIONS

These data suggest that the higher

frequency of outlets providing

calorically-dense foods and alcohol may

contribute to greater obesity prevalence

in residents of low-income communities

More research is needed to thoroughly

document environmental determinants

of health and obesity

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

From 1994-1998 HUD randomly assigned

4498 women with children living in public

housing in high-poverty urban census

tracts to one of three groups (1) housing

vouchers redeemable only if they moved

to a low-poverty census tract (2)

unrestricted vouchers or (3) control group

(no vouchers)

Ludwig et al NEJM 201136516

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

10-12 year follow-up showed modest but

potentially important reductions in the

prevalence of extreme obesity amp diabetes in the

group moving from a neighborhood with high

poverty on one of low poverty compared to the

control group

No differences between the group receiving

traditional vouchers amp the control group

ldquoNeighborhoods matterrdquo

Ludwig et al NEJM 201136516

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance traffic safety in areas where

persons are or could be physically active

--Community-scale urban design amp land use policies to

promote physical activity including design components

to improve street lighting infrastructure projects to

increase safety of pedestrian street crossing and use of

traffic calming approaches such as speed humps amp

traffic circles are effective in increasing physical activity

--Both community-scale amp street-scale policies amp practices

are effective in increasing physical activity

Recommended Community Strategies Encourage Communities to Organize for Change

Participate in community coalitions or

partnerships to address obesity

--Little evidence is available to determine the

impact of community coalitions on obesity

prevention

--The presence of anti-smoking community

coalitions has been associated with lower rates

of tobacco consumption

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

$103 million awarded to 61 states and

communities including state amp local government

agencies tribes amp territories amp state amp local non-

profit organizations

To build capacity to implement changes for

community prevention efforts to ensure long-

term success

To implement evidence-based and practice-

based programs to improve health amp wellness

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Priority areas are

Tobacco-free living

Active living and healthy eating

Evidence-based quality clinical and other

preventive health services for prevention

and control of high blood pressure and

high cholesterol

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Applicants proposed specific activities in

line with their chosen priority areas in their

applications

Grantee activities will not be finalized until

plans are negotiated with CDC by early

2012

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Capacity-Building Award

The Confederated Tribes of The Chehalis

Reservation is receiving a $498663 planning

award to build capacity to support healthy

lifestyles among their tribal population of 1500

in Washington State

Work will target tobacco-free living active living

and healthy eating and quality clinical and other

healthy serviceswwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Implementation Award

Austin TX Dept of Health and Human Services

is receiving $1026158 to serve Travis County

(Austin) to expand efforts in tobacco-free living

active living and healthy eating quality clinical

and other preventive services social and

emotional wellness and healthy and safe

physical environmentswwwcdcgov1052011

Building sustainable healthy

communities Bottom line

Obesity is an environmental problem

Despite progress in genetic research public health advances only will occur when we take the environment seriously

Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment

Until we do this we will not make substantial progress in addressing the epidemic of obesity

Poston amp Foreyt Atherosclerosis 1999

Whatrsquos the best approach

Integrate all sectors of society into community

change interventions

Incorporate

Science amp Technology

Education

FamilyCommunity

Healthcare

Arts amp Entertainment

Law amp Politics

Commerce amp Trade

Sectors of Society

Arts amp Entertainm

ent

Commerce amp Trade

Education

FamilyCommunity

Healthcare

Law amp Politics

Science amp Technology

Project FIT rationale design and baseline characteristics of a school- and community-

based intervention to address physical activity and healthy eating among low-income

elementary school children

Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D

Oh HJ Orth J Randall S Mayfield K Holmes D

Source

Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu

Abstract

BACKGROUND

This paper describes Project FIT a collaboration between the public school system local

health systems physicians neighborhood associations businesses faith-based leaders

community agencies and university researchers to develop a multi-faceted approach to

promote physical activity and healthy eating toward the general goal of preventing and

reducing childhood obesity among children in Grand Rapids MI USA

METHODSDESIGN

There are four overall components to Project FIT school community social marketing and

school staff wellness - all that focus on 1) increasing access to safe and affordable physical

activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)

improving the affordability and availability of nutritious food in the neighborhoods surrounding

the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding

nutrition and physical activity among school staff parents and students 4) impacting the

culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging

dialogue among all community partners to leverage existing programs and introduce new

ones

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Restrict availability of less healthy foods amp

beverages in public service venues

--No peer-reviewed studies examined the impact

designed to restrict availability of less healthy

foods in public service venues

--21 states have policies that restrict the sale of

competitive foods in schools beyond USDA

regulations however no studies have evaluated

the impact of the policies

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Institute smaller portion size options in public

service venues

--Evidence is lacking to demonstrate effectiveness

of population-based interventions aimed at

reducing portion sizes in public service venues

--Evidence from clinical studies in laboratories

demonstrates decreasing portion sizes

decreases energy intake

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Limit advertisements of less healthy foods amp

beverages

--Little evidence is available regarding the impact

of restricting advertising on purchasing amp

consumption of less healthy foods

--Cross-sectional time-series studies of tobacco-

control efforts suggest an association between

advertising bans amp decreased tobacco

consumption

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Discourage consumption of sugar-sweetened

beverages

--One longitudinal study of a school-based

intervention among Native-American high school

students showed a substantial reduction in

sugar-sweetened beverages over a 3-year

period

--A RCT of a home-based intervention that

eliminated sugar-sweetened beverages showed

reduction in BMI scores

Recommended Community Strategies Strategies to encourage breastfeeding

Increase support for breastfeeding

--Evidence directly linking environmental

interventions that support breastfeeding with

obesity-related outcomes is lacking

--Epidemiologic studies indicate that breastfeeding

helps prevent pediatric obesity

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Require physical education in schools

--14 studies have demonstrated that school-based

PE was effective in increasing levels of physical

activity and improving physical fitness

--Minimum of 150 minwk in elementary schools

225 minwk in middle schools and high schools

throughout the school year as recommended by

NASPE

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Increase opportunities for extracurricular

physical activity

--Participation in after-school programs increased

studentsrsquo level of physical activity amp improved

obesity-related outcomes (improved CV fitness

reduced body fat)

--2 pilot studies providing extracurricular physical

activity showed increased levels of PA amp

decreased sedentary behavior

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Reduce screen time in public service venues

--A school-based RCT indicated that children who

reduced their television videotape amp video

game use had significant decrease in BMI tricep

skin fold thickness amp waist circumference

compared to controls

--Spending less time watching television is

associated with increased physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Improve access to outdoor recreational

facilities

--Review of 108 studies indicated that access to facilities

and programs for recreation near their homes amp time

spent outdoors correlated positively with increased

physical activity among childrenamp adults

--Perceptions that footpaths are safe for walking was

significantly associated with adults being classified as

physically active at a level sufficient for health benefits

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting

bicycling

--Longitudinal intervention studies have

demonstrated that improving bicycling

infrastructure is associated with increased

frequency of bicycling

--Cross-sectional studies indicated a significant

association between bicycling infrastructure amp

frequency of biking

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting walking

--Reviews of cross-sectional studies of

environmental correlates of physical activity amp

walking generally find a positive association

between infrastructure supportive of walking amp

physical activity

--Identifying amp creating safe routes to school

together with educational components

increased the number of students walking to

school

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Locating schools within easy walking

distance of residential areas

--Community-scale urban design amp land use policies amp

practices including locating schools stores workplaces

amp recreation areas close to residential areas are

effective in facilitating an increase in levels of physical

activity

--Majority of efforts to encourage walking to school involve

improving the routes rather than improving the location

of schools

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Improve access to public transportation

--Insufficient evidence exists to determine

effectiveness of transportation policies in

increasing the level of physical activity or

improving fitness

--1 study indicated that 29 of individuals who

walk to and from public transit achieve at least

30 minutes of daily physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Zone for mixed-use development

--Allows residential commercial institutional amp

other public land uses to be located in close

proximity to one another

--Studies using correlation analyses amp regression

models indicated that mixed land use was

associated with increased walking amp cycling

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance personal safety in areas where

persons are or could be physically active

--Cross-sectional studies have demonstrated a

negative relationship between crime rates andor

perceived safety amp physical activity in

neighborhoods

--Few intervention studies have evaluated the

impact of policies amp practices to improve

personal safety on physical activity

Geospatial Mapping Linking Urban

Environments to Health Risk

Measure association between environmental variables amp health risk factors

Assess relationships between variables at different levels of analysis

Used in conjunction with linear analyses

Our Community Environmental Model

of Obesity

Community Factors

Poverty

Crime

Grocery Quality

Restaurants

Parks

Sidewalks

Fast Food Outlets

Recreational

Facilities

Individual Factors

Dietary Intake

Physical Activity

Genetics

Family History

StressCoping

Eating Disorders

Psychological

Problems

Weight

Status

Chosen Neighborhoods

Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped

We then matched census-block groups within the income groups by population density and percentage of minority representation

One matched block group per income level was randomly selected

Prevalence of Obesity in

Block-Groups

0

5

10

15

20

25

30

35

40

45

50

Ag

e-a

dju

sted

Ob

esit

y P

rev

ale

nce

(

)

High-Income Low-Income

Age-standardized to the 1990 US Census

Density of Environmental Factors in the

Community Contributes to a ldquoToxicrdquo

Obesity Environment

0

2

4

6

8

10

12

14

16

18

Fast-food Convenience Store Bars

Den

sity

10

00

perso

ns

High-Income Low-Income

COMMUNITYrsquoS PERCEPTION OF SAFETY

0

5

10

15

20

25

30

35

40

Daytime Nighttime

Perc

en

t (

) F

eeli

ng

So

mew

hat

Safe

or

Un

safe

Low-Income High-Income

Percent Substandard (or worse) Housing

or Ground Conditions

of Residential Properties

0

10

20

30

Structural Grounds

Perc

en

t (

)

Low-Income High-Income

CONCLUSIONS

These data suggest that the higher

frequency of outlets providing

calorically-dense foods and alcohol may

contribute to greater obesity prevalence

in residents of low-income communities

More research is needed to thoroughly

document environmental determinants

of health and obesity

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

From 1994-1998 HUD randomly assigned

4498 women with children living in public

housing in high-poverty urban census

tracts to one of three groups (1) housing

vouchers redeemable only if they moved

to a low-poverty census tract (2)

unrestricted vouchers or (3) control group

(no vouchers)

Ludwig et al NEJM 201136516

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

10-12 year follow-up showed modest but

potentially important reductions in the

prevalence of extreme obesity amp diabetes in the

group moving from a neighborhood with high

poverty on one of low poverty compared to the

control group

No differences between the group receiving

traditional vouchers amp the control group

ldquoNeighborhoods matterrdquo

Ludwig et al NEJM 201136516

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance traffic safety in areas where

persons are or could be physically active

--Community-scale urban design amp land use policies to

promote physical activity including design components

to improve street lighting infrastructure projects to

increase safety of pedestrian street crossing and use of

traffic calming approaches such as speed humps amp

traffic circles are effective in increasing physical activity

--Both community-scale amp street-scale policies amp practices

are effective in increasing physical activity

Recommended Community Strategies Encourage Communities to Organize for Change

Participate in community coalitions or

partnerships to address obesity

--Little evidence is available to determine the

impact of community coalitions on obesity

prevention

--The presence of anti-smoking community

coalitions has been associated with lower rates

of tobacco consumption

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

$103 million awarded to 61 states and

communities including state amp local government

agencies tribes amp territories amp state amp local non-

profit organizations

To build capacity to implement changes for

community prevention efforts to ensure long-

term success

To implement evidence-based and practice-

based programs to improve health amp wellness

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Priority areas are

Tobacco-free living

Active living and healthy eating

Evidence-based quality clinical and other

preventive health services for prevention

and control of high blood pressure and

high cholesterol

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Applicants proposed specific activities in

line with their chosen priority areas in their

applications

Grantee activities will not be finalized until

plans are negotiated with CDC by early

2012

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Capacity-Building Award

The Confederated Tribes of The Chehalis

Reservation is receiving a $498663 planning

award to build capacity to support healthy

lifestyles among their tribal population of 1500

in Washington State

Work will target tobacco-free living active living

and healthy eating and quality clinical and other

healthy serviceswwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Implementation Award

Austin TX Dept of Health and Human Services

is receiving $1026158 to serve Travis County

(Austin) to expand efforts in tobacco-free living

active living and healthy eating quality clinical

and other preventive services social and

emotional wellness and healthy and safe

physical environmentswwwcdcgov1052011

Building sustainable healthy

communities Bottom line

Obesity is an environmental problem

Despite progress in genetic research public health advances only will occur when we take the environment seriously

Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment

Until we do this we will not make substantial progress in addressing the epidemic of obesity

Poston amp Foreyt Atherosclerosis 1999

Whatrsquos the best approach

Integrate all sectors of society into community

change interventions

Incorporate

Science amp Technology

Education

FamilyCommunity

Healthcare

Arts amp Entertainment

Law amp Politics

Commerce amp Trade

Sectors of Society

Arts amp Entertainm

ent

Commerce amp Trade

Education

FamilyCommunity

Healthcare

Law amp Politics

Science amp Technology

Project FIT rationale design and baseline characteristics of a school- and community-

based intervention to address physical activity and healthy eating among low-income

elementary school children

Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D

Oh HJ Orth J Randall S Mayfield K Holmes D

Source

Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu

Abstract

BACKGROUND

This paper describes Project FIT a collaboration between the public school system local

health systems physicians neighborhood associations businesses faith-based leaders

community agencies and university researchers to develop a multi-faceted approach to

promote physical activity and healthy eating toward the general goal of preventing and

reducing childhood obesity among children in Grand Rapids MI USA

METHODSDESIGN

There are four overall components to Project FIT school community social marketing and

school staff wellness - all that focus on 1) increasing access to safe and affordable physical

activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)

improving the affordability and availability of nutritious food in the neighborhoods surrounding

the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding

nutrition and physical activity among school staff parents and students 4) impacting the

culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging

dialogue among all community partners to leverage existing programs and introduce new

ones

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Institute smaller portion size options in public

service venues

--Evidence is lacking to demonstrate effectiveness

of population-based interventions aimed at

reducing portion sizes in public service venues

--Evidence from clinical studies in laboratories

demonstrates decreasing portion sizes

decreases energy intake

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Limit advertisements of less healthy foods amp

beverages

--Little evidence is available regarding the impact

of restricting advertising on purchasing amp

consumption of less healthy foods

--Cross-sectional time-series studies of tobacco-

control efforts suggest an association between

advertising bans amp decreased tobacco

consumption

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Discourage consumption of sugar-sweetened

beverages

--One longitudinal study of a school-based

intervention among Native-American high school

students showed a substantial reduction in

sugar-sweetened beverages over a 3-year

period

--A RCT of a home-based intervention that

eliminated sugar-sweetened beverages showed

reduction in BMI scores

Recommended Community Strategies Strategies to encourage breastfeeding

Increase support for breastfeeding

--Evidence directly linking environmental

interventions that support breastfeeding with

obesity-related outcomes is lacking

--Epidemiologic studies indicate that breastfeeding

helps prevent pediatric obesity

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Require physical education in schools

--14 studies have demonstrated that school-based

PE was effective in increasing levels of physical

activity and improving physical fitness

--Minimum of 150 minwk in elementary schools

225 minwk in middle schools and high schools

throughout the school year as recommended by

NASPE

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Increase opportunities for extracurricular

physical activity

--Participation in after-school programs increased

studentsrsquo level of physical activity amp improved

obesity-related outcomes (improved CV fitness

reduced body fat)

--2 pilot studies providing extracurricular physical

activity showed increased levels of PA amp

decreased sedentary behavior

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Reduce screen time in public service venues

--A school-based RCT indicated that children who

reduced their television videotape amp video

game use had significant decrease in BMI tricep

skin fold thickness amp waist circumference

compared to controls

--Spending less time watching television is

associated with increased physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Improve access to outdoor recreational

facilities

--Review of 108 studies indicated that access to facilities

and programs for recreation near their homes amp time

spent outdoors correlated positively with increased

physical activity among childrenamp adults

--Perceptions that footpaths are safe for walking was

significantly associated with adults being classified as

physically active at a level sufficient for health benefits

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting

bicycling

--Longitudinal intervention studies have

demonstrated that improving bicycling

infrastructure is associated with increased

frequency of bicycling

--Cross-sectional studies indicated a significant

association between bicycling infrastructure amp

frequency of biking

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting walking

--Reviews of cross-sectional studies of

environmental correlates of physical activity amp

walking generally find a positive association

between infrastructure supportive of walking amp

physical activity

--Identifying amp creating safe routes to school

together with educational components

increased the number of students walking to

school

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Locating schools within easy walking

distance of residential areas

--Community-scale urban design amp land use policies amp

practices including locating schools stores workplaces

amp recreation areas close to residential areas are

effective in facilitating an increase in levels of physical

activity

--Majority of efforts to encourage walking to school involve

improving the routes rather than improving the location

of schools

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Improve access to public transportation

--Insufficient evidence exists to determine

effectiveness of transportation policies in

increasing the level of physical activity or

improving fitness

--1 study indicated that 29 of individuals who

walk to and from public transit achieve at least

30 minutes of daily physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Zone for mixed-use development

--Allows residential commercial institutional amp

other public land uses to be located in close

proximity to one another

--Studies using correlation analyses amp regression

models indicated that mixed land use was

associated with increased walking amp cycling

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance personal safety in areas where

persons are or could be physically active

--Cross-sectional studies have demonstrated a

negative relationship between crime rates andor

perceived safety amp physical activity in

neighborhoods

--Few intervention studies have evaluated the

impact of policies amp practices to improve

personal safety on physical activity

Geospatial Mapping Linking Urban

Environments to Health Risk

Measure association between environmental variables amp health risk factors

Assess relationships between variables at different levels of analysis

Used in conjunction with linear analyses

Our Community Environmental Model

of Obesity

Community Factors

Poverty

Crime

Grocery Quality

Restaurants

Parks

Sidewalks

Fast Food Outlets

Recreational

Facilities

Individual Factors

Dietary Intake

Physical Activity

Genetics

Family History

StressCoping

Eating Disorders

Psychological

Problems

Weight

Status

Chosen Neighborhoods

Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped

We then matched census-block groups within the income groups by population density and percentage of minority representation

One matched block group per income level was randomly selected

Prevalence of Obesity in

Block-Groups

0

5

10

15

20

25

30

35

40

45

50

Ag

e-a

dju

sted

Ob

esit

y P

rev

ale

nce

(

)

High-Income Low-Income

Age-standardized to the 1990 US Census

Density of Environmental Factors in the

Community Contributes to a ldquoToxicrdquo

Obesity Environment

0

2

4

6

8

10

12

14

16

18

Fast-food Convenience Store Bars

Den

sity

10

00

perso

ns

High-Income Low-Income

COMMUNITYrsquoS PERCEPTION OF SAFETY

0

5

10

15

20

25

30

35

40

Daytime Nighttime

Perc

en

t (

) F

eeli

ng

So

mew

hat

Safe

or

Un

safe

Low-Income High-Income

Percent Substandard (or worse) Housing

or Ground Conditions

of Residential Properties

0

10

20

30

Structural Grounds

Perc

en

t (

)

Low-Income High-Income

CONCLUSIONS

These data suggest that the higher

frequency of outlets providing

calorically-dense foods and alcohol may

contribute to greater obesity prevalence

in residents of low-income communities

More research is needed to thoroughly

document environmental determinants

of health and obesity

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

From 1994-1998 HUD randomly assigned

4498 women with children living in public

housing in high-poverty urban census

tracts to one of three groups (1) housing

vouchers redeemable only if they moved

to a low-poverty census tract (2)

unrestricted vouchers or (3) control group

(no vouchers)

Ludwig et al NEJM 201136516

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

10-12 year follow-up showed modest but

potentially important reductions in the

prevalence of extreme obesity amp diabetes in the

group moving from a neighborhood with high

poverty on one of low poverty compared to the

control group

No differences between the group receiving

traditional vouchers amp the control group

ldquoNeighborhoods matterrdquo

Ludwig et al NEJM 201136516

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance traffic safety in areas where

persons are or could be physically active

--Community-scale urban design amp land use policies to

promote physical activity including design components

to improve street lighting infrastructure projects to

increase safety of pedestrian street crossing and use of

traffic calming approaches such as speed humps amp

traffic circles are effective in increasing physical activity

--Both community-scale amp street-scale policies amp practices

are effective in increasing physical activity

Recommended Community Strategies Encourage Communities to Organize for Change

Participate in community coalitions or

partnerships to address obesity

--Little evidence is available to determine the

impact of community coalitions on obesity

prevention

--The presence of anti-smoking community

coalitions has been associated with lower rates

of tobacco consumption

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

$103 million awarded to 61 states and

communities including state amp local government

agencies tribes amp territories amp state amp local non-

profit organizations

To build capacity to implement changes for

community prevention efforts to ensure long-

term success

To implement evidence-based and practice-

based programs to improve health amp wellness

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Priority areas are

Tobacco-free living

Active living and healthy eating

Evidence-based quality clinical and other

preventive health services for prevention

and control of high blood pressure and

high cholesterol

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Applicants proposed specific activities in

line with their chosen priority areas in their

applications

Grantee activities will not be finalized until

plans are negotiated with CDC by early

2012

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Capacity-Building Award

The Confederated Tribes of The Chehalis

Reservation is receiving a $498663 planning

award to build capacity to support healthy

lifestyles among their tribal population of 1500

in Washington State

Work will target tobacco-free living active living

and healthy eating and quality clinical and other

healthy serviceswwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Implementation Award

Austin TX Dept of Health and Human Services

is receiving $1026158 to serve Travis County

(Austin) to expand efforts in tobacco-free living

active living and healthy eating quality clinical

and other preventive services social and

emotional wellness and healthy and safe

physical environmentswwwcdcgov1052011

Building sustainable healthy

communities Bottom line

Obesity is an environmental problem

Despite progress in genetic research public health advances only will occur when we take the environment seriously

Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment

Until we do this we will not make substantial progress in addressing the epidemic of obesity

Poston amp Foreyt Atherosclerosis 1999

Whatrsquos the best approach

Integrate all sectors of society into community

change interventions

Incorporate

Science amp Technology

Education

FamilyCommunity

Healthcare

Arts amp Entertainment

Law amp Politics

Commerce amp Trade

Sectors of Society

Arts amp Entertainm

ent

Commerce amp Trade

Education

FamilyCommunity

Healthcare

Law amp Politics

Science amp Technology

Project FIT rationale design and baseline characteristics of a school- and community-

based intervention to address physical activity and healthy eating among low-income

elementary school children

Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D

Oh HJ Orth J Randall S Mayfield K Holmes D

Source

Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu

Abstract

BACKGROUND

This paper describes Project FIT a collaboration between the public school system local

health systems physicians neighborhood associations businesses faith-based leaders

community agencies and university researchers to develop a multi-faceted approach to

promote physical activity and healthy eating toward the general goal of preventing and

reducing childhood obesity among children in Grand Rapids MI USA

METHODSDESIGN

There are four overall components to Project FIT school community social marketing and

school staff wellness - all that focus on 1) increasing access to safe and affordable physical

activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)

improving the affordability and availability of nutritious food in the neighborhoods surrounding

the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding

nutrition and physical activity among school staff parents and students 4) impacting the

culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging

dialogue among all community partners to leverage existing programs and introduce new

ones

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Limit advertisements of less healthy foods amp

beverages

--Little evidence is available regarding the impact

of restricting advertising on purchasing amp

consumption of less healthy foods

--Cross-sectional time-series studies of tobacco-

control efforts suggest an association between

advertising bans amp decreased tobacco

consumption

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Discourage consumption of sugar-sweetened

beverages

--One longitudinal study of a school-based

intervention among Native-American high school

students showed a substantial reduction in

sugar-sweetened beverages over a 3-year

period

--A RCT of a home-based intervention that

eliminated sugar-sweetened beverages showed

reduction in BMI scores

Recommended Community Strategies Strategies to encourage breastfeeding

Increase support for breastfeeding

--Evidence directly linking environmental

interventions that support breastfeeding with

obesity-related outcomes is lacking

--Epidemiologic studies indicate that breastfeeding

helps prevent pediatric obesity

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Require physical education in schools

--14 studies have demonstrated that school-based

PE was effective in increasing levels of physical

activity and improving physical fitness

--Minimum of 150 minwk in elementary schools

225 minwk in middle schools and high schools

throughout the school year as recommended by

NASPE

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Increase opportunities for extracurricular

physical activity

--Participation in after-school programs increased

studentsrsquo level of physical activity amp improved

obesity-related outcomes (improved CV fitness

reduced body fat)

--2 pilot studies providing extracurricular physical

activity showed increased levels of PA amp

decreased sedentary behavior

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Reduce screen time in public service venues

--A school-based RCT indicated that children who

reduced their television videotape amp video

game use had significant decrease in BMI tricep

skin fold thickness amp waist circumference

compared to controls

--Spending less time watching television is

associated with increased physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Improve access to outdoor recreational

facilities

--Review of 108 studies indicated that access to facilities

and programs for recreation near their homes amp time

spent outdoors correlated positively with increased

physical activity among childrenamp adults

--Perceptions that footpaths are safe for walking was

significantly associated with adults being classified as

physically active at a level sufficient for health benefits

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting

bicycling

--Longitudinal intervention studies have

demonstrated that improving bicycling

infrastructure is associated with increased

frequency of bicycling

--Cross-sectional studies indicated a significant

association between bicycling infrastructure amp

frequency of biking

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting walking

--Reviews of cross-sectional studies of

environmental correlates of physical activity amp

walking generally find a positive association

between infrastructure supportive of walking amp

physical activity

--Identifying amp creating safe routes to school

together with educational components

increased the number of students walking to

school

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Locating schools within easy walking

distance of residential areas

--Community-scale urban design amp land use policies amp

practices including locating schools stores workplaces

amp recreation areas close to residential areas are

effective in facilitating an increase in levels of physical

activity

--Majority of efforts to encourage walking to school involve

improving the routes rather than improving the location

of schools

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Improve access to public transportation

--Insufficient evidence exists to determine

effectiveness of transportation policies in

increasing the level of physical activity or

improving fitness

--1 study indicated that 29 of individuals who

walk to and from public transit achieve at least

30 minutes of daily physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Zone for mixed-use development

--Allows residential commercial institutional amp

other public land uses to be located in close

proximity to one another

--Studies using correlation analyses amp regression

models indicated that mixed land use was

associated with increased walking amp cycling

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance personal safety in areas where

persons are or could be physically active

--Cross-sectional studies have demonstrated a

negative relationship between crime rates andor

perceived safety amp physical activity in

neighborhoods

--Few intervention studies have evaluated the

impact of policies amp practices to improve

personal safety on physical activity

Geospatial Mapping Linking Urban

Environments to Health Risk

Measure association between environmental variables amp health risk factors

Assess relationships between variables at different levels of analysis

Used in conjunction with linear analyses

Our Community Environmental Model

of Obesity

Community Factors

Poverty

Crime

Grocery Quality

Restaurants

Parks

Sidewalks

Fast Food Outlets

Recreational

Facilities

Individual Factors

Dietary Intake

Physical Activity

Genetics

Family History

StressCoping

Eating Disorders

Psychological

Problems

Weight

Status

Chosen Neighborhoods

Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped

We then matched census-block groups within the income groups by population density and percentage of minority representation

One matched block group per income level was randomly selected

Prevalence of Obesity in

Block-Groups

0

5

10

15

20

25

30

35

40

45

50

Ag

e-a

dju

sted

Ob

esit

y P

rev

ale

nce

(

)

High-Income Low-Income

Age-standardized to the 1990 US Census

Density of Environmental Factors in the

Community Contributes to a ldquoToxicrdquo

Obesity Environment

0

2

4

6

8

10

12

14

16

18

Fast-food Convenience Store Bars

Den

sity

10

00

perso

ns

High-Income Low-Income

COMMUNITYrsquoS PERCEPTION OF SAFETY

0

5

10

15

20

25

30

35

40

Daytime Nighttime

Perc

en

t (

) F

eeli

ng

So

mew

hat

Safe

or

Un

safe

Low-Income High-Income

Percent Substandard (or worse) Housing

or Ground Conditions

of Residential Properties

0

10

20

30

Structural Grounds

Perc

en

t (

)

Low-Income High-Income

CONCLUSIONS

These data suggest that the higher

frequency of outlets providing

calorically-dense foods and alcohol may

contribute to greater obesity prevalence

in residents of low-income communities

More research is needed to thoroughly

document environmental determinants

of health and obesity

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

From 1994-1998 HUD randomly assigned

4498 women with children living in public

housing in high-poverty urban census

tracts to one of three groups (1) housing

vouchers redeemable only if they moved

to a low-poverty census tract (2)

unrestricted vouchers or (3) control group

(no vouchers)

Ludwig et al NEJM 201136516

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

10-12 year follow-up showed modest but

potentially important reductions in the

prevalence of extreme obesity amp diabetes in the

group moving from a neighborhood with high

poverty on one of low poverty compared to the

control group

No differences between the group receiving

traditional vouchers amp the control group

ldquoNeighborhoods matterrdquo

Ludwig et al NEJM 201136516

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance traffic safety in areas where

persons are or could be physically active

--Community-scale urban design amp land use policies to

promote physical activity including design components

to improve street lighting infrastructure projects to

increase safety of pedestrian street crossing and use of

traffic calming approaches such as speed humps amp

traffic circles are effective in increasing physical activity

--Both community-scale amp street-scale policies amp practices

are effective in increasing physical activity

Recommended Community Strategies Encourage Communities to Organize for Change

Participate in community coalitions or

partnerships to address obesity

--Little evidence is available to determine the

impact of community coalitions on obesity

prevention

--The presence of anti-smoking community

coalitions has been associated with lower rates

of tobacco consumption

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

$103 million awarded to 61 states and

communities including state amp local government

agencies tribes amp territories amp state amp local non-

profit organizations

To build capacity to implement changes for

community prevention efforts to ensure long-

term success

To implement evidence-based and practice-

based programs to improve health amp wellness

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Priority areas are

Tobacco-free living

Active living and healthy eating

Evidence-based quality clinical and other

preventive health services for prevention

and control of high blood pressure and

high cholesterol

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Applicants proposed specific activities in

line with their chosen priority areas in their

applications

Grantee activities will not be finalized until

plans are negotiated with CDC by early

2012

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Capacity-Building Award

The Confederated Tribes of The Chehalis

Reservation is receiving a $498663 planning

award to build capacity to support healthy

lifestyles among their tribal population of 1500

in Washington State

Work will target tobacco-free living active living

and healthy eating and quality clinical and other

healthy serviceswwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Implementation Award

Austin TX Dept of Health and Human Services

is receiving $1026158 to serve Travis County

(Austin) to expand efforts in tobacco-free living

active living and healthy eating quality clinical

and other preventive services social and

emotional wellness and healthy and safe

physical environmentswwwcdcgov1052011

Building sustainable healthy

communities Bottom line

Obesity is an environmental problem

Despite progress in genetic research public health advances only will occur when we take the environment seriously

Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment

Until we do this we will not make substantial progress in addressing the epidemic of obesity

Poston amp Foreyt Atherosclerosis 1999

Whatrsquos the best approach

Integrate all sectors of society into community

change interventions

Incorporate

Science amp Technology

Education

FamilyCommunity

Healthcare

Arts amp Entertainment

Law amp Politics

Commerce amp Trade

Sectors of Society

Arts amp Entertainm

ent

Commerce amp Trade

Education

FamilyCommunity

Healthcare

Law amp Politics

Science amp Technology

Project FIT rationale design and baseline characteristics of a school- and community-

based intervention to address physical activity and healthy eating among low-income

elementary school children

Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D

Oh HJ Orth J Randall S Mayfield K Holmes D

Source

Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu

Abstract

BACKGROUND

This paper describes Project FIT a collaboration between the public school system local

health systems physicians neighborhood associations businesses faith-based leaders

community agencies and university researchers to develop a multi-faceted approach to

promote physical activity and healthy eating toward the general goal of preventing and

reducing childhood obesity among children in Grand Rapids MI USA

METHODSDESIGN

There are four overall components to Project FIT school community social marketing and

school staff wellness - all that focus on 1) increasing access to safe and affordable physical

activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)

improving the affordability and availability of nutritious food in the neighborhoods surrounding

the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding

nutrition and physical activity among school staff parents and students 4) impacting the

culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging

dialogue among all community partners to leverage existing programs and introduce new

ones

Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices

Discourage consumption of sugar-sweetened

beverages

--One longitudinal study of a school-based

intervention among Native-American high school

students showed a substantial reduction in

sugar-sweetened beverages over a 3-year

period

--A RCT of a home-based intervention that

eliminated sugar-sweetened beverages showed

reduction in BMI scores

Recommended Community Strategies Strategies to encourage breastfeeding

Increase support for breastfeeding

--Evidence directly linking environmental

interventions that support breastfeeding with

obesity-related outcomes is lacking

--Epidemiologic studies indicate that breastfeeding

helps prevent pediatric obesity

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Require physical education in schools

--14 studies have demonstrated that school-based

PE was effective in increasing levels of physical

activity and improving physical fitness

--Minimum of 150 minwk in elementary schools

225 minwk in middle schools and high schools

throughout the school year as recommended by

NASPE

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Increase opportunities for extracurricular

physical activity

--Participation in after-school programs increased

studentsrsquo level of physical activity amp improved

obesity-related outcomes (improved CV fitness

reduced body fat)

--2 pilot studies providing extracurricular physical

activity showed increased levels of PA amp

decreased sedentary behavior

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Reduce screen time in public service venues

--A school-based RCT indicated that children who

reduced their television videotape amp video

game use had significant decrease in BMI tricep

skin fold thickness amp waist circumference

compared to controls

--Spending less time watching television is

associated with increased physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Improve access to outdoor recreational

facilities

--Review of 108 studies indicated that access to facilities

and programs for recreation near their homes amp time

spent outdoors correlated positively with increased

physical activity among childrenamp adults

--Perceptions that footpaths are safe for walking was

significantly associated with adults being classified as

physically active at a level sufficient for health benefits

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting

bicycling

--Longitudinal intervention studies have

demonstrated that improving bicycling

infrastructure is associated with increased

frequency of bicycling

--Cross-sectional studies indicated a significant

association between bicycling infrastructure amp

frequency of biking

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting walking

--Reviews of cross-sectional studies of

environmental correlates of physical activity amp

walking generally find a positive association

between infrastructure supportive of walking amp

physical activity

--Identifying amp creating safe routes to school

together with educational components

increased the number of students walking to

school

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Locating schools within easy walking

distance of residential areas

--Community-scale urban design amp land use policies amp

practices including locating schools stores workplaces

amp recreation areas close to residential areas are

effective in facilitating an increase in levels of physical

activity

--Majority of efforts to encourage walking to school involve

improving the routes rather than improving the location

of schools

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Improve access to public transportation

--Insufficient evidence exists to determine

effectiveness of transportation policies in

increasing the level of physical activity or

improving fitness

--1 study indicated that 29 of individuals who

walk to and from public transit achieve at least

30 minutes of daily physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Zone for mixed-use development

--Allows residential commercial institutional amp

other public land uses to be located in close

proximity to one another

--Studies using correlation analyses amp regression

models indicated that mixed land use was

associated with increased walking amp cycling

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance personal safety in areas where

persons are or could be physically active

--Cross-sectional studies have demonstrated a

negative relationship between crime rates andor

perceived safety amp physical activity in

neighborhoods

--Few intervention studies have evaluated the

impact of policies amp practices to improve

personal safety on physical activity

Geospatial Mapping Linking Urban

Environments to Health Risk

Measure association between environmental variables amp health risk factors

Assess relationships between variables at different levels of analysis

Used in conjunction with linear analyses

Our Community Environmental Model

of Obesity

Community Factors

Poverty

Crime

Grocery Quality

Restaurants

Parks

Sidewalks

Fast Food Outlets

Recreational

Facilities

Individual Factors

Dietary Intake

Physical Activity

Genetics

Family History

StressCoping

Eating Disorders

Psychological

Problems

Weight

Status

Chosen Neighborhoods

Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped

We then matched census-block groups within the income groups by population density and percentage of minority representation

One matched block group per income level was randomly selected

Prevalence of Obesity in

Block-Groups

0

5

10

15

20

25

30

35

40

45

50

Ag

e-a

dju

sted

Ob

esit

y P

rev

ale

nce

(

)

High-Income Low-Income

Age-standardized to the 1990 US Census

Density of Environmental Factors in the

Community Contributes to a ldquoToxicrdquo

Obesity Environment

0

2

4

6

8

10

12

14

16

18

Fast-food Convenience Store Bars

Den

sity

10

00

perso

ns

High-Income Low-Income

COMMUNITYrsquoS PERCEPTION OF SAFETY

0

5

10

15

20

25

30

35

40

Daytime Nighttime

Perc

en

t (

) F

eeli

ng

So

mew

hat

Safe

or

Un

safe

Low-Income High-Income

Percent Substandard (or worse) Housing

or Ground Conditions

of Residential Properties

0

10

20

30

Structural Grounds

Perc

en

t (

)

Low-Income High-Income

CONCLUSIONS

These data suggest that the higher

frequency of outlets providing

calorically-dense foods and alcohol may

contribute to greater obesity prevalence

in residents of low-income communities

More research is needed to thoroughly

document environmental determinants

of health and obesity

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

From 1994-1998 HUD randomly assigned

4498 women with children living in public

housing in high-poverty urban census

tracts to one of three groups (1) housing

vouchers redeemable only if they moved

to a low-poverty census tract (2)

unrestricted vouchers or (3) control group

(no vouchers)

Ludwig et al NEJM 201136516

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

10-12 year follow-up showed modest but

potentially important reductions in the

prevalence of extreme obesity amp diabetes in the

group moving from a neighborhood with high

poverty on one of low poverty compared to the

control group

No differences between the group receiving

traditional vouchers amp the control group

ldquoNeighborhoods matterrdquo

Ludwig et al NEJM 201136516

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance traffic safety in areas where

persons are or could be physically active

--Community-scale urban design amp land use policies to

promote physical activity including design components

to improve street lighting infrastructure projects to

increase safety of pedestrian street crossing and use of

traffic calming approaches such as speed humps amp

traffic circles are effective in increasing physical activity

--Both community-scale amp street-scale policies amp practices

are effective in increasing physical activity

Recommended Community Strategies Encourage Communities to Organize for Change

Participate in community coalitions or

partnerships to address obesity

--Little evidence is available to determine the

impact of community coalitions on obesity

prevention

--The presence of anti-smoking community

coalitions has been associated with lower rates

of tobacco consumption

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

$103 million awarded to 61 states and

communities including state amp local government

agencies tribes amp territories amp state amp local non-

profit organizations

To build capacity to implement changes for

community prevention efforts to ensure long-

term success

To implement evidence-based and practice-

based programs to improve health amp wellness

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Priority areas are

Tobacco-free living

Active living and healthy eating

Evidence-based quality clinical and other

preventive health services for prevention

and control of high blood pressure and

high cholesterol

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Applicants proposed specific activities in

line with their chosen priority areas in their

applications

Grantee activities will not be finalized until

plans are negotiated with CDC by early

2012

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Capacity-Building Award

The Confederated Tribes of The Chehalis

Reservation is receiving a $498663 planning

award to build capacity to support healthy

lifestyles among their tribal population of 1500

in Washington State

Work will target tobacco-free living active living

and healthy eating and quality clinical and other

healthy serviceswwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Implementation Award

Austin TX Dept of Health and Human Services

is receiving $1026158 to serve Travis County

(Austin) to expand efforts in tobacco-free living

active living and healthy eating quality clinical

and other preventive services social and

emotional wellness and healthy and safe

physical environmentswwwcdcgov1052011

Building sustainable healthy

communities Bottom line

Obesity is an environmental problem

Despite progress in genetic research public health advances only will occur when we take the environment seriously

Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment

Until we do this we will not make substantial progress in addressing the epidemic of obesity

Poston amp Foreyt Atherosclerosis 1999

Whatrsquos the best approach

Integrate all sectors of society into community

change interventions

Incorporate

Science amp Technology

Education

FamilyCommunity

Healthcare

Arts amp Entertainment

Law amp Politics

Commerce amp Trade

Sectors of Society

Arts amp Entertainm

ent

Commerce amp Trade

Education

FamilyCommunity

Healthcare

Law amp Politics

Science amp Technology

Project FIT rationale design and baseline characteristics of a school- and community-

based intervention to address physical activity and healthy eating among low-income

elementary school children

Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D

Oh HJ Orth J Randall S Mayfield K Holmes D

Source

Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu

Abstract

BACKGROUND

This paper describes Project FIT a collaboration between the public school system local

health systems physicians neighborhood associations businesses faith-based leaders

community agencies and university researchers to develop a multi-faceted approach to

promote physical activity and healthy eating toward the general goal of preventing and

reducing childhood obesity among children in Grand Rapids MI USA

METHODSDESIGN

There are four overall components to Project FIT school community social marketing and

school staff wellness - all that focus on 1) increasing access to safe and affordable physical

activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)

improving the affordability and availability of nutritious food in the neighborhoods surrounding

the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding

nutrition and physical activity among school staff parents and students 4) impacting the

culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging

dialogue among all community partners to leverage existing programs and introduce new

ones

Recommended Community Strategies Strategies to encourage breastfeeding

Increase support for breastfeeding

--Evidence directly linking environmental

interventions that support breastfeeding with

obesity-related outcomes is lacking

--Epidemiologic studies indicate that breastfeeding

helps prevent pediatric obesity

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Require physical education in schools

--14 studies have demonstrated that school-based

PE was effective in increasing levels of physical

activity and improving physical fitness

--Minimum of 150 minwk in elementary schools

225 minwk in middle schools and high schools

throughout the school year as recommended by

NASPE

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Increase opportunities for extracurricular

physical activity

--Participation in after-school programs increased

studentsrsquo level of physical activity amp improved

obesity-related outcomes (improved CV fitness

reduced body fat)

--2 pilot studies providing extracurricular physical

activity showed increased levels of PA amp

decreased sedentary behavior

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Reduce screen time in public service venues

--A school-based RCT indicated that children who

reduced their television videotape amp video

game use had significant decrease in BMI tricep

skin fold thickness amp waist circumference

compared to controls

--Spending less time watching television is

associated with increased physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Improve access to outdoor recreational

facilities

--Review of 108 studies indicated that access to facilities

and programs for recreation near their homes amp time

spent outdoors correlated positively with increased

physical activity among childrenamp adults

--Perceptions that footpaths are safe for walking was

significantly associated with adults being classified as

physically active at a level sufficient for health benefits

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting

bicycling

--Longitudinal intervention studies have

demonstrated that improving bicycling

infrastructure is associated with increased

frequency of bicycling

--Cross-sectional studies indicated a significant

association between bicycling infrastructure amp

frequency of biking

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting walking

--Reviews of cross-sectional studies of

environmental correlates of physical activity amp

walking generally find a positive association

between infrastructure supportive of walking amp

physical activity

--Identifying amp creating safe routes to school

together with educational components

increased the number of students walking to

school

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Locating schools within easy walking

distance of residential areas

--Community-scale urban design amp land use policies amp

practices including locating schools stores workplaces

amp recreation areas close to residential areas are

effective in facilitating an increase in levels of physical

activity

--Majority of efforts to encourage walking to school involve

improving the routes rather than improving the location

of schools

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Improve access to public transportation

--Insufficient evidence exists to determine

effectiveness of transportation policies in

increasing the level of physical activity or

improving fitness

--1 study indicated that 29 of individuals who

walk to and from public transit achieve at least

30 minutes of daily physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Zone for mixed-use development

--Allows residential commercial institutional amp

other public land uses to be located in close

proximity to one another

--Studies using correlation analyses amp regression

models indicated that mixed land use was

associated with increased walking amp cycling

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance personal safety in areas where

persons are or could be physically active

--Cross-sectional studies have demonstrated a

negative relationship between crime rates andor

perceived safety amp physical activity in

neighborhoods

--Few intervention studies have evaluated the

impact of policies amp practices to improve

personal safety on physical activity

Geospatial Mapping Linking Urban

Environments to Health Risk

Measure association between environmental variables amp health risk factors

Assess relationships between variables at different levels of analysis

Used in conjunction with linear analyses

Our Community Environmental Model

of Obesity

Community Factors

Poverty

Crime

Grocery Quality

Restaurants

Parks

Sidewalks

Fast Food Outlets

Recreational

Facilities

Individual Factors

Dietary Intake

Physical Activity

Genetics

Family History

StressCoping

Eating Disorders

Psychological

Problems

Weight

Status

Chosen Neighborhoods

Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped

We then matched census-block groups within the income groups by population density and percentage of minority representation

One matched block group per income level was randomly selected

Prevalence of Obesity in

Block-Groups

0

5

10

15

20

25

30

35

40

45

50

Ag

e-a

dju

sted

Ob

esit

y P

rev

ale

nce

(

)

High-Income Low-Income

Age-standardized to the 1990 US Census

Density of Environmental Factors in the

Community Contributes to a ldquoToxicrdquo

Obesity Environment

0

2

4

6

8

10

12

14

16

18

Fast-food Convenience Store Bars

Den

sity

10

00

perso

ns

High-Income Low-Income

COMMUNITYrsquoS PERCEPTION OF SAFETY

0

5

10

15

20

25

30

35

40

Daytime Nighttime

Perc

en

t (

) F

eeli

ng

So

mew

hat

Safe

or

Un

safe

Low-Income High-Income

Percent Substandard (or worse) Housing

or Ground Conditions

of Residential Properties

0

10

20

30

Structural Grounds

Perc

en

t (

)

Low-Income High-Income

CONCLUSIONS

These data suggest that the higher

frequency of outlets providing

calorically-dense foods and alcohol may

contribute to greater obesity prevalence

in residents of low-income communities

More research is needed to thoroughly

document environmental determinants

of health and obesity

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

From 1994-1998 HUD randomly assigned

4498 women with children living in public

housing in high-poverty urban census

tracts to one of three groups (1) housing

vouchers redeemable only if they moved

to a low-poverty census tract (2)

unrestricted vouchers or (3) control group

(no vouchers)

Ludwig et al NEJM 201136516

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

10-12 year follow-up showed modest but

potentially important reductions in the

prevalence of extreme obesity amp diabetes in the

group moving from a neighborhood with high

poverty on one of low poverty compared to the

control group

No differences between the group receiving

traditional vouchers amp the control group

ldquoNeighborhoods matterrdquo

Ludwig et al NEJM 201136516

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance traffic safety in areas where

persons are or could be physically active

--Community-scale urban design amp land use policies to

promote physical activity including design components

to improve street lighting infrastructure projects to

increase safety of pedestrian street crossing and use of

traffic calming approaches such as speed humps amp

traffic circles are effective in increasing physical activity

--Both community-scale amp street-scale policies amp practices

are effective in increasing physical activity

Recommended Community Strategies Encourage Communities to Organize for Change

Participate in community coalitions or

partnerships to address obesity

--Little evidence is available to determine the

impact of community coalitions on obesity

prevention

--The presence of anti-smoking community

coalitions has been associated with lower rates

of tobacco consumption

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

$103 million awarded to 61 states and

communities including state amp local government

agencies tribes amp territories amp state amp local non-

profit organizations

To build capacity to implement changes for

community prevention efforts to ensure long-

term success

To implement evidence-based and practice-

based programs to improve health amp wellness

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Priority areas are

Tobacco-free living

Active living and healthy eating

Evidence-based quality clinical and other

preventive health services for prevention

and control of high blood pressure and

high cholesterol

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Applicants proposed specific activities in

line with their chosen priority areas in their

applications

Grantee activities will not be finalized until

plans are negotiated with CDC by early

2012

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Capacity-Building Award

The Confederated Tribes of The Chehalis

Reservation is receiving a $498663 planning

award to build capacity to support healthy

lifestyles among their tribal population of 1500

in Washington State

Work will target tobacco-free living active living

and healthy eating and quality clinical and other

healthy serviceswwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Implementation Award

Austin TX Dept of Health and Human Services

is receiving $1026158 to serve Travis County

(Austin) to expand efforts in tobacco-free living

active living and healthy eating quality clinical

and other preventive services social and

emotional wellness and healthy and safe

physical environmentswwwcdcgov1052011

Building sustainable healthy

communities Bottom line

Obesity is an environmental problem

Despite progress in genetic research public health advances only will occur when we take the environment seriously

Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment

Until we do this we will not make substantial progress in addressing the epidemic of obesity

Poston amp Foreyt Atherosclerosis 1999

Whatrsquos the best approach

Integrate all sectors of society into community

change interventions

Incorporate

Science amp Technology

Education

FamilyCommunity

Healthcare

Arts amp Entertainment

Law amp Politics

Commerce amp Trade

Sectors of Society

Arts amp Entertainm

ent

Commerce amp Trade

Education

FamilyCommunity

Healthcare

Law amp Politics

Science amp Technology

Project FIT rationale design and baseline characteristics of a school- and community-

based intervention to address physical activity and healthy eating among low-income

elementary school children

Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D

Oh HJ Orth J Randall S Mayfield K Holmes D

Source

Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu

Abstract

BACKGROUND

This paper describes Project FIT a collaboration between the public school system local

health systems physicians neighborhood associations businesses faith-based leaders

community agencies and university researchers to develop a multi-faceted approach to

promote physical activity and healthy eating toward the general goal of preventing and

reducing childhood obesity among children in Grand Rapids MI USA

METHODSDESIGN

There are four overall components to Project FIT school community social marketing and

school staff wellness - all that focus on 1) increasing access to safe and affordable physical

activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)

improving the affordability and availability of nutritious food in the neighborhoods surrounding

the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding

nutrition and physical activity among school staff parents and students 4) impacting the

culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging

dialogue among all community partners to leverage existing programs and introduce new

ones

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Require physical education in schools

--14 studies have demonstrated that school-based

PE was effective in increasing levels of physical

activity and improving physical fitness

--Minimum of 150 minwk in elementary schools

225 minwk in middle schools and high schools

throughout the school year as recommended by

NASPE

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Increase opportunities for extracurricular

physical activity

--Participation in after-school programs increased

studentsrsquo level of physical activity amp improved

obesity-related outcomes (improved CV fitness

reduced body fat)

--2 pilot studies providing extracurricular physical

activity showed increased levels of PA amp

decreased sedentary behavior

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Reduce screen time in public service venues

--A school-based RCT indicated that children who

reduced their television videotape amp video

game use had significant decrease in BMI tricep

skin fold thickness amp waist circumference

compared to controls

--Spending less time watching television is

associated with increased physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Improve access to outdoor recreational

facilities

--Review of 108 studies indicated that access to facilities

and programs for recreation near their homes amp time

spent outdoors correlated positively with increased

physical activity among childrenamp adults

--Perceptions that footpaths are safe for walking was

significantly associated with adults being classified as

physically active at a level sufficient for health benefits

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting

bicycling

--Longitudinal intervention studies have

demonstrated that improving bicycling

infrastructure is associated with increased

frequency of bicycling

--Cross-sectional studies indicated a significant

association between bicycling infrastructure amp

frequency of biking

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting walking

--Reviews of cross-sectional studies of

environmental correlates of physical activity amp

walking generally find a positive association

between infrastructure supportive of walking amp

physical activity

--Identifying amp creating safe routes to school

together with educational components

increased the number of students walking to

school

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Locating schools within easy walking

distance of residential areas

--Community-scale urban design amp land use policies amp

practices including locating schools stores workplaces

amp recreation areas close to residential areas are

effective in facilitating an increase in levels of physical

activity

--Majority of efforts to encourage walking to school involve

improving the routes rather than improving the location

of schools

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Improve access to public transportation

--Insufficient evidence exists to determine

effectiveness of transportation policies in

increasing the level of physical activity or

improving fitness

--1 study indicated that 29 of individuals who

walk to and from public transit achieve at least

30 minutes of daily physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Zone for mixed-use development

--Allows residential commercial institutional amp

other public land uses to be located in close

proximity to one another

--Studies using correlation analyses amp regression

models indicated that mixed land use was

associated with increased walking amp cycling

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance personal safety in areas where

persons are or could be physically active

--Cross-sectional studies have demonstrated a

negative relationship between crime rates andor

perceived safety amp physical activity in

neighborhoods

--Few intervention studies have evaluated the

impact of policies amp practices to improve

personal safety on physical activity

Geospatial Mapping Linking Urban

Environments to Health Risk

Measure association between environmental variables amp health risk factors

Assess relationships between variables at different levels of analysis

Used in conjunction with linear analyses

Our Community Environmental Model

of Obesity

Community Factors

Poverty

Crime

Grocery Quality

Restaurants

Parks

Sidewalks

Fast Food Outlets

Recreational

Facilities

Individual Factors

Dietary Intake

Physical Activity

Genetics

Family History

StressCoping

Eating Disorders

Psychological

Problems

Weight

Status

Chosen Neighborhoods

Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped

We then matched census-block groups within the income groups by population density and percentage of minority representation

One matched block group per income level was randomly selected

Prevalence of Obesity in

Block-Groups

0

5

10

15

20

25

30

35

40

45

50

Ag

e-a

dju

sted

Ob

esit

y P

rev

ale

nce

(

)

High-Income Low-Income

Age-standardized to the 1990 US Census

Density of Environmental Factors in the

Community Contributes to a ldquoToxicrdquo

Obesity Environment

0

2

4

6

8

10

12

14

16

18

Fast-food Convenience Store Bars

Den

sity

10

00

perso

ns

High-Income Low-Income

COMMUNITYrsquoS PERCEPTION OF SAFETY

0

5

10

15

20

25

30

35

40

Daytime Nighttime

Perc

en

t (

) F

eeli

ng

So

mew

hat

Safe

or

Un

safe

Low-Income High-Income

Percent Substandard (or worse) Housing

or Ground Conditions

of Residential Properties

0

10

20

30

Structural Grounds

Perc

en

t (

)

Low-Income High-Income

CONCLUSIONS

These data suggest that the higher

frequency of outlets providing

calorically-dense foods and alcohol may

contribute to greater obesity prevalence

in residents of low-income communities

More research is needed to thoroughly

document environmental determinants

of health and obesity

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

From 1994-1998 HUD randomly assigned

4498 women with children living in public

housing in high-poverty urban census

tracts to one of three groups (1) housing

vouchers redeemable only if they moved

to a low-poverty census tract (2)

unrestricted vouchers or (3) control group

(no vouchers)

Ludwig et al NEJM 201136516

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

10-12 year follow-up showed modest but

potentially important reductions in the

prevalence of extreme obesity amp diabetes in the

group moving from a neighborhood with high

poverty on one of low poverty compared to the

control group

No differences between the group receiving

traditional vouchers amp the control group

ldquoNeighborhoods matterrdquo

Ludwig et al NEJM 201136516

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance traffic safety in areas where

persons are or could be physically active

--Community-scale urban design amp land use policies to

promote physical activity including design components

to improve street lighting infrastructure projects to

increase safety of pedestrian street crossing and use of

traffic calming approaches such as speed humps amp

traffic circles are effective in increasing physical activity

--Both community-scale amp street-scale policies amp practices

are effective in increasing physical activity

Recommended Community Strategies Encourage Communities to Organize for Change

Participate in community coalitions or

partnerships to address obesity

--Little evidence is available to determine the

impact of community coalitions on obesity

prevention

--The presence of anti-smoking community

coalitions has been associated with lower rates

of tobacco consumption

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

$103 million awarded to 61 states and

communities including state amp local government

agencies tribes amp territories amp state amp local non-

profit organizations

To build capacity to implement changes for

community prevention efforts to ensure long-

term success

To implement evidence-based and practice-

based programs to improve health amp wellness

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Priority areas are

Tobacco-free living

Active living and healthy eating

Evidence-based quality clinical and other

preventive health services for prevention

and control of high blood pressure and

high cholesterol

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Applicants proposed specific activities in

line with their chosen priority areas in their

applications

Grantee activities will not be finalized until

plans are negotiated with CDC by early

2012

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Capacity-Building Award

The Confederated Tribes of The Chehalis

Reservation is receiving a $498663 planning

award to build capacity to support healthy

lifestyles among their tribal population of 1500

in Washington State

Work will target tobacco-free living active living

and healthy eating and quality clinical and other

healthy serviceswwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Implementation Award

Austin TX Dept of Health and Human Services

is receiving $1026158 to serve Travis County

(Austin) to expand efforts in tobacco-free living

active living and healthy eating quality clinical

and other preventive services social and

emotional wellness and healthy and safe

physical environmentswwwcdcgov1052011

Building sustainable healthy

communities Bottom line

Obesity is an environmental problem

Despite progress in genetic research public health advances only will occur when we take the environment seriously

Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment

Until we do this we will not make substantial progress in addressing the epidemic of obesity

Poston amp Foreyt Atherosclerosis 1999

Whatrsquos the best approach

Integrate all sectors of society into community

change interventions

Incorporate

Science amp Technology

Education

FamilyCommunity

Healthcare

Arts amp Entertainment

Law amp Politics

Commerce amp Trade

Sectors of Society

Arts amp Entertainm

ent

Commerce amp Trade

Education

FamilyCommunity

Healthcare

Law amp Politics

Science amp Technology

Project FIT rationale design and baseline characteristics of a school- and community-

based intervention to address physical activity and healthy eating among low-income

elementary school children

Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D

Oh HJ Orth J Randall S Mayfield K Holmes D

Source

Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu

Abstract

BACKGROUND

This paper describes Project FIT a collaboration between the public school system local

health systems physicians neighborhood associations businesses faith-based leaders

community agencies and university researchers to develop a multi-faceted approach to

promote physical activity and healthy eating toward the general goal of preventing and

reducing childhood obesity among children in Grand Rapids MI USA

METHODSDESIGN

There are four overall components to Project FIT school community social marketing and

school staff wellness - all that focus on 1) increasing access to safe and affordable physical

activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)

improving the affordability and availability of nutritious food in the neighborhoods surrounding

the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding

nutrition and physical activity among school staff parents and students 4) impacting the

culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging

dialogue among all community partners to leverage existing programs and introduce new

ones

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Increase opportunities for extracurricular

physical activity

--Participation in after-school programs increased

studentsrsquo level of physical activity amp improved

obesity-related outcomes (improved CV fitness

reduced body fat)

--2 pilot studies providing extracurricular physical

activity showed increased levels of PA amp

decreased sedentary behavior

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Reduce screen time in public service venues

--A school-based RCT indicated that children who

reduced their television videotape amp video

game use had significant decrease in BMI tricep

skin fold thickness amp waist circumference

compared to controls

--Spending less time watching television is

associated with increased physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Improve access to outdoor recreational

facilities

--Review of 108 studies indicated that access to facilities

and programs for recreation near their homes amp time

spent outdoors correlated positively with increased

physical activity among childrenamp adults

--Perceptions that footpaths are safe for walking was

significantly associated with adults being classified as

physically active at a level sufficient for health benefits

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting

bicycling

--Longitudinal intervention studies have

demonstrated that improving bicycling

infrastructure is associated with increased

frequency of bicycling

--Cross-sectional studies indicated a significant

association between bicycling infrastructure amp

frequency of biking

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting walking

--Reviews of cross-sectional studies of

environmental correlates of physical activity amp

walking generally find a positive association

between infrastructure supportive of walking amp

physical activity

--Identifying amp creating safe routes to school

together with educational components

increased the number of students walking to

school

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Locating schools within easy walking

distance of residential areas

--Community-scale urban design amp land use policies amp

practices including locating schools stores workplaces

amp recreation areas close to residential areas are

effective in facilitating an increase in levels of physical

activity

--Majority of efforts to encourage walking to school involve

improving the routes rather than improving the location

of schools

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Improve access to public transportation

--Insufficient evidence exists to determine

effectiveness of transportation policies in

increasing the level of physical activity or

improving fitness

--1 study indicated that 29 of individuals who

walk to and from public transit achieve at least

30 minutes of daily physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Zone for mixed-use development

--Allows residential commercial institutional amp

other public land uses to be located in close

proximity to one another

--Studies using correlation analyses amp regression

models indicated that mixed land use was

associated with increased walking amp cycling

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance personal safety in areas where

persons are or could be physically active

--Cross-sectional studies have demonstrated a

negative relationship between crime rates andor

perceived safety amp physical activity in

neighborhoods

--Few intervention studies have evaluated the

impact of policies amp practices to improve

personal safety on physical activity

Geospatial Mapping Linking Urban

Environments to Health Risk

Measure association between environmental variables amp health risk factors

Assess relationships between variables at different levels of analysis

Used in conjunction with linear analyses

Our Community Environmental Model

of Obesity

Community Factors

Poverty

Crime

Grocery Quality

Restaurants

Parks

Sidewalks

Fast Food Outlets

Recreational

Facilities

Individual Factors

Dietary Intake

Physical Activity

Genetics

Family History

StressCoping

Eating Disorders

Psychological

Problems

Weight

Status

Chosen Neighborhoods

Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped

We then matched census-block groups within the income groups by population density and percentage of minority representation

One matched block group per income level was randomly selected

Prevalence of Obesity in

Block-Groups

0

5

10

15

20

25

30

35

40

45

50

Ag

e-a

dju

sted

Ob

esit

y P

rev

ale

nce

(

)

High-Income Low-Income

Age-standardized to the 1990 US Census

Density of Environmental Factors in the

Community Contributes to a ldquoToxicrdquo

Obesity Environment

0

2

4

6

8

10

12

14

16

18

Fast-food Convenience Store Bars

Den

sity

10

00

perso

ns

High-Income Low-Income

COMMUNITYrsquoS PERCEPTION OF SAFETY

0

5

10

15

20

25

30

35

40

Daytime Nighttime

Perc

en

t (

) F

eeli

ng

So

mew

hat

Safe

or

Un

safe

Low-Income High-Income

Percent Substandard (or worse) Housing

or Ground Conditions

of Residential Properties

0

10

20

30

Structural Grounds

Perc

en

t (

)

Low-Income High-Income

CONCLUSIONS

These data suggest that the higher

frequency of outlets providing

calorically-dense foods and alcohol may

contribute to greater obesity prevalence

in residents of low-income communities

More research is needed to thoroughly

document environmental determinants

of health and obesity

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

From 1994-1998 HUD randomly assigned

4498 women with children living in public

housing in high-poverty urban census

tracts to one of three groups (1) housing

vouchers redeemable only if they moved

to a low-poverty census tract (2)

unrestricted vouchers or (3) control group

(no vouchers)

Ludwig et al NEJM 201136516

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

10-12 year follow-up showed modest but

potentially important reductions in the

prevalence of extreme obesity amp diabetes in the

group moving from a neighborhood with high

poverty on one of low poverty compared to the

control group

No differences between the group receiving

traditional vouchers amp the control group

ldquoNeighborhoods matterrdquo

Ludwig et al NEJM 201136516

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance traffic safety in areas where

persons are or could be physically active

--Community-scale urban design amp land use policies to

promote physical activity including design components

to improve street lighting infrastructure projects to

increase safety of pedestrian street crossing and use of

traffic calming approaches such as speed humps amp

traffic circles are effective in increasing physical activity

--Both community-scale amp street-scale policies amp practices

are effective in increasing physical activity

Recommended Community Strategies Encourage Communities to Organize for Change

Participate in community coalitions or

partnerships to address obesity

--Little evidence is available to determine the

impact of community coalitions on obesity

prevention

--The presence of anti-smoking community

coalitions has been associated with lower rates

of tobacco consumption

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

$103 million awarded to 61 states and

communities including state amp local government

agencies tribes amp territories amp state amp local non-

profit organizations

To build capacity to implement changes for

community prevention efforts to ensure long-

term success

To implement evidence-based and practice-

based programs to improve health amp wellness

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Priority areas are

Tobacco-free living

Active living and healthy eating

Evidence-based quality clinical and other

preventive health services for prevention

and control of high blood pressure and

high cholesterol

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Applicants proposed specific activities in

line with their chosen priority areas in their

applications

Grantee activities will not be finalized until

plans are negotiated with CDC by early

2012

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Capacity-Building Award

The Confederated Tribes of The Chehalis

Reservation is receiving a $498663 planning

award to build capacity to support healthy

lifestyles among their tribal population of 1500

in Washington State

Work will target tobacco-free living active living

and healthy eating and quality clinical and other

healthy serviceswwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Implementation Award

Austin TX Dept of Health and Human Services

is receiving $1026158 to serve Travis County

(Austin) to expand efforts in tobacco-free living

active living and healthy eating quality clinical

and other preventive services social and

emotional wellness and healthy and safe

physical environmentswwwcdcgov1052011

Building sustainable healthy

communities Bottom line

Obesity is an environmental problem

Despite progress in genetic research public health advances only will occur when we take the environment seriously

Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment

Until we do this we will not make substantial progress in addressing the epidemic of obesity

Poston amp Foreyt Atherosclerosis 1999

Whatrsquos the best approach

Integrate all sectors of society into community

change interventions

Incorporate

Science amp Technology

Education

FamilyCommunity

Healthcare

Arts amp Entertainment

Law amp Politics

Commerce amp Trade

Sectors of Society

Arts amp Entertainm

ent

Commerce amp Trade

Education

FamilyCommunity

Healthcare

Law amp Politics

Science amp Technology

Project FIT rationale design and baseline characteristics of a school- and community-

based intervention to address physical activity and healthy eating among low-income

elementary school children

Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D

Oh HJ Orth J Randall S Mayfield K Holmes D

Source

Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu

Abstract

BACKGROUND

This paper describes Project FIT a collaboration between the public school system local

health systems physicians neighborhood associations businesses faith-based leaders

community agencies and university researchers to develop a multi-faceted approach to

promote physical activity and healthy eating toward the general goal of preventing and

reducing childhood obesity among children in Grand Rapids MI USA

METHODSDESIGN

There are four overall components to Project FIT school community social marketing and

school staff wellness - all that focus on 1) increasing access to safe and affordable physical

activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)

improving the affordability and availability of nutritious food in the neighborhoods surrounding

the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding

nutrition and physical activity among school staff parents and students 4) impacting the

culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging

dialogue among all community partners to leverage existing programs and introduce new

ones

Recommended Community Strategies Strategies to encourage physical activity or limit sedentary

activity among children and youth

Reduce screen time in public service venues

--A school-based RCT indicated that children who

reduced their television videotape amp video

game use had significant decrease in BMI tricep

skin fold thickness amp waist circumference

compared to controls

--Spending less time watching television is

associated with increased physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Improve access to outdoor recreational

facilities

--Review of 108 studies indicated that access to facilities

and programs for recreation near their homes amp time

spent outdoors correlated positively with increased

physical activity among childrenamp adults

--Perceptions that footpaths are safe for walking was

significantly associated with adults being classified as

physically active at a level sufficient for health benefits

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting

bicycling

--Longitudinal intervention studies have

demonstrated that improving bicycling

infrastructure is associated with increased

frequency of bicycling

--Cross-sectional studies indicated a significant

association between bicycling infrastructure amp

frequency of biking

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting walking

--Reviews of cross-sectional studies of

environmental correlates of physical activity amp

walking generally find a positive association

between infrastructure supportive of walking amp

physical activity

--Identifying amp creating safe routes to school

together with educational components

increased the number of students walking to

school

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Locating schools within easy walking

distance of residential areas

--Community-scale urban design amp land use policies amp

practices including locating schools stores workplaces

amp recreation areas close to residential areas are

effective in facilitating an increase in levels of physical

activity

--Majority of efforts to encourage walking to school involve

improving the routes rather than improving the location

of schools

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Improve access to public transportation

--Insufficient evidence exists to determine

effectiveness of transportation policies in

increasing the level of physical activity or

improving fitness

--1 study indicated that 29 of individuals who

walk to and from public transit achieve at least

30 minutes of daily physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Zone for mixed-use development

--Allows residential commercial institutional amp

other public land uses to be located in close

proximity to one another

--Studies using correlation analyses amp regression

models indicated that mixed land use was

associated with increased walking amp cycling

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance personal safety in areas where

persons are or could be physically active

--Cross-sectional studies have demonstrated a

negative relationship between crime rates andor

perceived safety amp physical activity in

neighborhoods

--Few intervention studies have evaluated the

impact of policies amp practices to improve

personal safety on physical activity

Geospatial Mapping Linking Urban

Environments to Health Risk

Measure association between environmental variables amp health risk factors

Assess relationships between variables at different levels of analysis

Used in conjunction with linear analyses

Our Community Environmental Model

of Obesity

Community Factors

Poverty

Crime

Grocery Quality

Restaurants

Parks

Sidewalks

Fast Food Outlets

Recreational

Facilities

Individual Factors

Dietary Intake

Physical Activity

Genetics

Family History

StressCoping

Eating Disorders

Psychological

Problems

Weight

Status

Chosen Neighborhoods

Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped

We then matched census-block groups within the income groups by population density and percentage of minority representation

One matched block group per income level was randomly selected

Prevalence of Obesity in

Block-Groups

0

5

10

15

20

25

30

35

40

45

50

Ag

e-a

dju

sted

Ob

esit

y P

rev

ale

nce

(

)

High-Income Low-Income

Age-standardized to the 1990 US Census

Density of Environmental Factors in the

Community Contributes to a ldquoToxicrdquo

Obesity Environment

0

2

4

6

8

10

12

14

16

18

Fast-food Convenience Store Bars

Den

sity

10

00

perso

ns

High-Income Low-Income

COMMUNITYrsquoS PERCEPTION OF SAFETY

0

5

10

15

20

25

30

35

40

Daytime Nighttime

Perc

en

t (

) F

eeli

ng

So

mew

hat

Safe

or

Un

safe

Low-Income High-Income

Percent Substandard (or worse) Housing

or Ground Conditions

of Residential Properties

0

10

20

30

Structural Grounds

Perc

en

t (

)

Low-Income High-Income

CONCLUSIONS

These data suggest that the higher

frequency of outlets providing

calorically-dense foods and alcohol may

contribute to greater obesity prevalence

in residents of low-income communities

More research is needed to thoroughly

document environmental determinants

of health and obesity

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

From 1994-1998 HUD randomly assigned

4498 women with children living in public

housing in high-poverty urban census

tracts to one of three groups (1) housing

vouchers redeemable only if they moved

to a low-poverty census tract (2)

unrestricted vouchers or (3) control group

(no vouchers)

Ludwig et al NEJM 201136516

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

10-12 year follow-up showed modest but

potentially important reductions in the

prevalence of extreme obesity amp diabetes in the

group moving from a neighborhood with high

poverty on one of low poverty compared to the

control group

No differences between the group receiving

traditional vouchers amp the control group

ldquoNeighborhoods matterrdquo

Ludwig et al NEJM 201136516

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance traffic safety in areas where

persons are or could be physically active

--Community-scale urban design amp land use policies to

promote physical activity including design components

to improve street lighting infrastructure projects to

increase safety of pedestrian street crossing and use of

traffic calming approaches such as speed humps amp

traffic circles are effective in increasing physical activity

--Both community-scale amp street-scale policies amp practices

are effective in increasing physical activity

Recommended Community Strategies Encourage Communities to Organize for Change

Participate in community coalitions or

partnerships to address obesity

--Little evidence is available to determine the

impact of community coalitions on obesity

prevention

--The presence of anti-smoking community

coalitions has been associated with lower rates

of tobacco consumption

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

$103 million awarded to 61 states and

communities including state amp local government

agencies tribes amp territories amp state amp local non-

profit organizations

To build capacity to implement changes for

community prevention efforts to ensure long-

term success

To implement evidence-based and practice-

based programs to improve health amp wellness

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Priority areas are

Tobacco-free living

Active living and healthy eating

Evidence-based quality clinical and other

preventive health services for prevention

and control of high blood pressure and

high cholesterol

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Applicants proposed specific activities in

line with their chosen priority areas in their

applications

Grantee activities will not be finalized until

plans are negotiated with CDC by early

2012

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Capacity-Building Award

The Confederated Tribes of The Chehalis

Reservation is receiving a $498663 planning

award to build capacity to support healthy

lifestyles among their tribal population of 1500

in Washington State

Work will target tobacco-free living active living

and healthy eating and quality clinical and other

healthy serviceswwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Implementation Award

Austin TX Dept of Health and Human Services

is receiving $1026158 to serve Travis County

(Austin) to expand efforts in tobacco-free living

active living and healthy eating quality clinical

and other preventive services social and

emotional wellness and healthy and safe

physical environmentswwwcdcgov1052011

Building sustainable healthy

communities Bottom line

Obesity is an environmental problem

Despite progress in genetic research public health advances only will occur when we take the environment seriously

Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment

Until we do this we will not make substantial progress in addressing the epidemic of obesity

Poston amp Foreyt Atherosclerosis 1999

Whatrsquos the best approach

Integrate all sectors of society into community

change interventions

Incorporate

Science amp Technology

Education

FamilyCommunity

Healthcare

Arts amp Entertainment

Law amp Politics

Commerce amp Trade

Sectors of Society

Arts amp Entertainm

ent

Commerce amp Trade

Education

FamilyCommunity

Healthcare

Law amp Politics

Science amp Technology

Project FIT rationale design and baseline characteristics of a school- and community-

based intervention to address physical activity and healthy eating among low-income

elementary school children

Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D

Oh HJ Orth J Randall S Mayfield K Holmes D

Source

Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu

Abstract

BACKGROUND

This paper describes Project FIT a collaboration between the public school system local

health systems physicians neighborhood associations businesses faith-based leaders

community agencies and university researchers to develop a multi-faceted approach to

promote physical activity and healthy eating toward the general goal of preventing and

reducing childhood obesity among children in Grand Rapids MI USA

METHODSDESIGN

There are four overall components to Project FIT school community social marketing and

school staff wellness - all that focus on 1) increasing access to safe and affordable physical

activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)

improving the affordability and availability of nutritious food in the neighborhoods surrounding

the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding

nutrition and physical activity among school staff parents and students 4) impacting the

culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging

dialogue among all community partners to leverage existing programs and introduce new

ones

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Improve access to outdoor recreational

facilities

--Review of 108 studies indicated that access to facilities

and programs for recreation near their homes amp time

spent outdoors correlated positively with increased

physical activity among childrenamp adults

--Perceptions that footpaths are safe for walking was

significantly associated with adults being classified as

physically active at a level sufficient for health benefits

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting

bicycling

--Longitudinal intervention studies have

demonstrated that improving bicycling

infrastructure is associated with increased

frequency of bicycling

--Cross-sectional studies indicated a significant

association between bicycling infrastructure amp

frequency of biking

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting walking

--Reviews of cross-sectional studies of

environmental correlates of physical activity amp

walking generally find a positive association

between infrastructure supportive of walking amp

physical activity

--Identifying amp creating safe routes to school

together with educational components

increased the number of students walking to

school

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Locating schools within easy walking

distance of residential areas

--Community-scale urban design amp land use policies amp

practices including locating schools stores workplaces

amp recreation areas close to residential areas are

effective in facilitating an increase in levels of physical

activity

--Majority of efforts to encourage walking to school involve

improving the routes rather than improving the location

of schools

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Improve access to public transportation

--Insufficient evidence exists to determine

effectiveness of transportation policies in

increasing the level of physical activity or

improving fitness

--1 study indicated that 29 of individuals who

walk to and from public transit achieve at least

30 minutes of daily physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Zone for mixed-use development

--Allows residential commercial institutional amp

other public land uses to be located in close

proximity to one another

--Studies using correlation analyses amp regression

models indicated that mixed land use was

associated with increased walking amp cycling

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance personal safety in areas where

persons are or could be physically active

--Cross-sectional studies have demonstrated a

negative relationship between crime rates andor

perceived safety amp physical activity in

neighborhoods

--Few intervention studies have evaluated the

impact of policies amp practices to improve

personal safety on physical activity

Geospatial Mapping Linking Urban

Environments to Health Risk

Measure association between environmental variables amp health risk factors

Assess relationships between variables at different levels of analysis

Used in conjunction with linear analyses

Our Community Environmental Model

of Obesity

Community Factors

Poverty

Crime

Grocery Quality

Restaurants

Parks

Sidewalks

Fast Food Outlets

Recreational

Facilities

Individual Factors

Dietary Intake

Physical Activity

Genetics

Family History

StressCoping

Eating Disorders

Psychological

Problems

Weight

Status

Chosen Neighborhoods

Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped

We then matched census-block groups within the income groups by population density and percentage of minority representation

One matched block group per income level was randomly selected

Prevalence of Obesity in

Block-Groups

0

5

10

15

20

25

30

35

40

45

50

Ag

e-a

dju

sted

Ob

esit

y P

rev

ale

nce

(

)

High-Income Low-Income

Age-standardized to the 1990 US Census

Density of Environmental Factors in the

Community Contributes to a ldquoToxicrdquo

Obesity Environment

0

2

4

6

8

10

12

14

16

18

Fast-food Convenience Store Bars

Den

sity

10

00

perso

ns

High-Income Low-Income

COMMUNITYrsquoS PERCEPTION OF SAFETY

0

5

10

15

20

25

30

35

40

Daytime Nighttime

Perc

en

t (

) F

eeli

ng

So

mew

hat

Safe

or

Un

safe

Low-Income High-Income

Percent Substandard (or worse) Housing

or Ground Conditions

of Residential Properties

0

10

20

30

Structural Grounds

Perc

en

t (

)

Low-Income High-Income

CONCLUSIONS

These data suggest that the higher

frequency of outlets providing

calorically-dense foods and alcohol may

contribute to greater obesity prevalence

in residents of low-income communities

More research is needed to thoroughly

document environmental determinants

of health and obesity

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

From 1994-1998 HUD randomly assigned

4498 women with children living in public

housing in high-poverty urban census

tracts to one of three groups (1) housing

vouchers redeemable only if they moved

to a low-poverty census tract (2)

unrestricted vouchers or (3) control group

(no vouchers)

Ludwig et al NEJM 201136516

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

10-12 year follow-up showed modest but

potentially important reductions in the

prevalence of extreme obesity amp diabetes in the

group moving from a neighborhood with high

poverty on one of low poverty compared to the

control group

No differences between the group receiving

traditional vouchers amp the control group

ldquoNeighborhoods matterrdquo

Ludwig et al NEJM 201136516

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance traffic safety in areas where

persons are or could be physically active

--Community-scale urban design amp land use policies to

promote physical activity including design components

to improve street lighting infrastructure projects to

increase safety of pedestrian street crossing and use of

traffic calming approaches such as speed humps amp

traffic circles are effective in increasing physical activity

--Both community-scale amp street-scale policies amp practices

are effective in increasing physical activity

Recommended Community Strategies Encourage Communities to Organize for Change

Participate in community coalitions or

partnerships to address obesity

--Little evidence is available to determine the

impact of community coalitions on obesity

prevention

--The presence of anti-smoking community

coalitions has been associated with lower rates

of tobacco consumption

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

$103 million awarded to 61 states and

communities including state amp local government

agencies tribes amp territories amp state amp local non-

profit organizations

To build capacity to implement changes for

community prevention efforts to ensure long-

term success

To implement evidence-based and practice-

based programs to improve health amp wellness

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Priority areas are

Tobacco-free living

Active living and healthy eating

Evidence-based quality clinical and other

preventive health services for prevention

and control of high blood pressure and

high cholesterol

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Applicants proposed specific activities in

line with their chosen priority areas in their

applications

Grantee activities will not be finalized until

plans are negotiated with CDC by early

2012

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Capacity-Building Award

The Confederated Tribes of The Chehalis

Reservation is receiving a $498663 planning

award to build capacity to support healthy

lifestyles among their tribal population of 1500

in Washington State

Work will target tobacco-free living active living

and healthy eating and quality clinical and other

healthy serviceswwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Implementation Award

Austin TX Dept of Health and Human Services

is receiving $1026158 to serve Travis County

(Austin) to expand efforts in tobacco-free living

active living and healthy eating quality clinical

and other preventive services social and

emotional wellness and healthy and safe

physical environmentswwwcdcgov1052011

Building sustainable healthy

communities Bottom line

Obesity is an environmental problem

Despite progress in genetic research public health advances only will occur when we take the environment seriously

Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment

Until we do this we will not make substantial progress in addressing the epidemic of obesity

Poston amp Foreyt Atherosclerosis 1999

Whatrsquos the best approach

Integrate all sectors of society into community

change interventions

Incorporate

Science amp Technology

Education

FamilyCommunity

Healthcare

Arts amp Entertainment

Law amp Politics

Commerce amp Trade

Sectors of Society

Arts amp Entertainm

ent

Commerce amp Trade

Education

FamilyCommunity

Healthcare

Law amp Politics

Science amp Technology

Project FIT rationale design and baseline characteristics of a school- and community-

based intervention to address physical activity and healthy eating among low-income

elementary school children

Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D

Oh HJ Orth J Randall S Mayfield K Holmes D

Source

Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu

Abstract

BACKGROUND

This paper describes Project FIT a collaboration between the public school system local

health systems physicians neighborhood associations businesses faith-based leaders

community agencies and university researchers to develop a multi-faceted approach to

promote physical activity and healthy eating toward the general goal of preventing and

reducing childhood obesity among children in Grand Rapids MI USA

METHODSDESIGN

There are four overall components to Project FIT school community social marketing and

school staff wellness - all that focus on 1) increasing access to safe and affordable physical

activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)

improving the affordability and availability of nutritious food in the neighborhoods surrounding

the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding

nutrition and physical activity among school staff parents and students 4) impacting the

culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging

dialogue among all community partners to leverage existing programs and introduce new

ones

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting

bicycling

--Longitudinal intervention studies have

demonstrated that improving bicycling

infrastructure is associated with increased

frequency of bicycling

--Cross-sectional studies indicated a significant

association between bicycling infrastructure amp

frequency of biking

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting walking

--Reviews of cross-sectional studies of

environmental correlates of physical activity amp

walking generally find a positive association

between infrastructure supportive of walking amp

physical activity

--Identifying amp creating safe routes to school

together with educational components

increased the number of students walking to

school

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Locating schools within easy walking

distance of residential areas

--Community-scale urban design amp land use policies amp

practices including locating schools stores workplaces

amp recreation areas close to residential areas are

effective in facilitating an increase in levels of physical

activity

--Majority of efforts to encourage walking to school involve

improving the routes rather than improving the location

of schools

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Improve access to public transportation

--Insufficient evidence exists to determine

effectiveness of transportation policies in

increasing the level of physical activity or

improving fitness

--1 study indicated that 29 of individuals who

walk to and from public transit achieve at least

30 minutes of daily physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Zone for mixed-use development

--Allows residential commercial institutional amp

other public land uses to be located in close

proximity to one another

--Studies using correlation analyses amp regression

models indicated that mixed land use was

associated with increased walking amp cycling

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance personal safety in areas where

persons are or could be physically active

--Cross-sectional studies have demonstrated a

negative relationship between crime rates andor

perceived safety amp physical activity in

neighborhoods

--Few intervention studies have evaluated the

impact of policies amp practices to improve

personal safety on physical activity

Geospatial Mapping Linking Urban

Environments to Health Risk

Measure association between environmental variables amp health risk factors

Assess relationships between variables at different levels of analysis

Used in conjunction with linear analyses

Our Community Environmental Model

of Obesity

Community Factors

Poverty

Crime

Grocery Quality

Restaurants

Parks

Sidewalks

Fast Food Outlets

Recreational

Facilities

Individual Factors

Dietary Intake

Physical Activity

Genetics

Family History

StressCoping

Eating Disorders

Psychological

Problems

Weight

Status

Chosen Neighborhoods

Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped

We then matched census-block groups within the income groups by population density and percentage of minority representation

One matched block group per income level was randomly selected

Prevalence of Obesity in

Block-Groups

0

5

10

15

20

25

30

35

40

45

50

Ag

e-a

dju

sted

Ob

esit

y P

rev

ale

nce

(

)

High-Income Low-Income

Age-standardized to the 1990 US Census

Density of Environmental Factors in the

Community Contributes to a ldquoToxicrdquo

Obesity Environment

0

2

4

6

8

10

12

14

16

18

Fast-food Convenience Store Bars

Den

sity

10

00

perso

ns

High-Income Low-Income

COMMUNITYrsquoS PERCEPTION OF SAFETY

0

5

10

15

20

25

30

35

40

Daytime Nighttime

Perc

en

t (

) F

eeli

ng

So

mew

hat

Safe

or

Un

safe

Low-Income High-Income

Percent Substandard (or worse) Housing

or Ground Conditions

of Residential Properties

0

10

20

30

Structural Grounds

Perc

en

t (

)

Low-Income High-Income

CONCLUSIONS

These data suggest that the higher

frequency of outlets providing

calorically-dense foods and alcohol may

contribute to greater obesity prevalence

in residents of low-income communities

More research is needed to thoroughly

document environmental determinants

of health and obesity

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

From 1994-1998 HUD randomly assigned

4498 women with children living in public

housing in high-poverty urban census

tracts to one of three groups (1) housing

vouchers redeemable only if they moved

to a low-poverty census tract (2)

unrestricted vouchers or (3) control group

(no vouchers)

Ludwig et al NEJM 201136516

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

10-12 year follow-up showed modest but

potentially important reductions in the

prevalence of extreme obesity amp diabetes in the

group moving from a neighborhood with high

poverty on one of low poverty compared to the

control group

No differences between the group receiving

traditional vouchers amp the control group

ldquoNeighborhoods matterrdquo

Ludwig et al NEJM 201136516

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance traffic safety in areas where

persons are or could be physically active

--Community-scale urban design amp land use policies to

promote physical activity including design components

to improve street lighting infrastructure projects to

increase safety of pedestrian street crossing and use of

traffic calming approaches such as speed humps amp

traffic circles are effective in increasing physical activity

--Both community-scale amp street-scale policies amp practices

are effective in increasing physical activity

Recommended Community Strategies Encourage Communities to Organize for Change

Participate in community coalitions or

partnerships to address obesity

--Little evidence is available to determine the

impact of community coalitions on obesity

prevention

--The presence of anti-smoking community

coalitions has been associated with lower rates

of tobacco consumption

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

$103 million awarded to 61 states and

communities including state amp local government

agencies tribes amp territories amp state amp local non-

profit organizations

To build capacity to implement changes for

community prevention efforts to ensure long-

term success

To implement evidence-based and practice-

based programs to improve health amp wellness

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Priority areas are

Tobacco-free living

Active living and healthy eating

Evidence-based quality clinical and other

preventive health services for prevention

and control of high blood pressure and

high cholesterol

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Applicants proposed specific activities in

line with their chosen priority areas in their

applications

Grantee activities will not be finalized until

plans are negotiated with CDC by early

2012

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Capacity-Building Award

The Confederated Tribes of The Chehalis

Reservation is receiving a $498663 planning

award to build capacity to support healthy

lifestyles among their tribal population of 1500

in Washington State

Work will target tobacco-free living active living

and healthy eating and quality clinical and other

healthy serviceswwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Implementation Award

Austin TX Dept of Health and Human Services

is receiving $1026158 to serve Travis County

(Austin) to expand efforts in tobacco-free living

active living and healthy eating quality clinical

and other preventive services social and

emotional wellness and healthy and safe

physical environmentswwwcdcgov1052011

Building sustainable healthy

communities Bottom line

Obesity is an environmental problem

Despite progress in genetic research public health advances only will occur when we take the environment seriously

Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment

Until we do this we will not make substantial progress in addressing the epidemic of obesity

Poston amp Foreyt Atherosclerosis 1999

Whatrsquos the best approach

Integrate all sectors of society into community

change interventions

Incorporate

Science amp Technology

Education

FamilyCommunity

Healthcare

Arts amp Entertainment

Law amp Politics

Commerce amp Trade

Sectors of Society

Arts amp Entertainm

ent

Commerce amp Trade

Education

FamilyCommunity

Healthcare

Law amp Politics

Science amp Technology

Project FIT rationale design and baseline characteristics of a school- and community-

based intervention to address physical activity and healthy eating among low-income

elementary school children

Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D

Oh HJ Orth J Randall S Mayfield K Holmes D

Source

Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu

Abstract

BACKGROUND

This paper describes Project FIT a collaboration between the public school system local

health systems physicians neighborhood associations businesses faith-based leaders

community agencies and university researchers to develop a multi-faceted approach to

promote physical activity and healthy eating toward the general goal of preventing and

reducing childhood obesity among children in Grand Rapids MI USA

METHODSDESIGN

There are four overall components to Project FIT school community social marketing and

school staff wellness - all that focus on 1) increasing access to safe and affordable physical

activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)

improving the affordability and availability of nutritious food in the neighborhoods surrounding

the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding

nutrition and physical activity among school staff parents and students 4) impacting the

culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging

dialogue among all community partners to leverage existing programs and introduce new

ones

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Enhance infrastructure supporting walking

--Reviews of cross-sectional studies of

environmental correlates of physical activity amp

walking generally find a positive association

between infrastructure supportive of walking amp

physical activity

--Identifying amp creating safe routes to school

together with educational components

increased the number of students walking to

school

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Locating schools within easy walking

distance of residential areas

--Community-scale urban design amp land use policies amp

practices including locating schools stores workplaces

amp recreation areas close to residential areas are

effective in facilitating an increase in levels of physical

activity

--Majority of efforts to encourage walking to school involve

improving the routes rather than improving the location

of schools

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Improve access to public transportation

--Insufficient evidence exists to determine

effectiveness of transportation policies in

increasing the level of physical activity or

improving fitness

--1 study indicated that 29 of individuals who

walk to and from public transit achieve at least

30 minutes of daily physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Zone for mixed-use development

--Allows residential commercial institutional amp

other public land uses to be located in close

proximity to one another

--Studies using correlation analyses amp regression

models indicated that mixed land use was

associated with increased walking amp cycling

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance personal safety in areas where

persons are or could be physically active

--Cross-sectional studies have demonstrated a

negative relationship between crime rates andor

perceived safety amp physical activity in

neighborhoods

--Few intervention studies have evaluated the

impact of policies amp practices to improve

personal safety on physical activity

Geospatial Mapping Linking Urban

Environments to Health Risk

Measure association between environmental variables amp health risk factors

Assess relationships between variables at different levels of analysis

Used in conjunction with linear analyses

Our Community Environmental Model

of Obesity

Community Factors

Poverty

Crime

Grocery Quality

Restaurants

Parks

Sidewalks

Fast Food Outlets

Recreational

Facilities

Individual Factors

Dietary Intake

Physical Activity

Genetics

Family History

StressCoping

Eating Disorders

Psychological

Problems

Weight

Status

Chosen Neighborhoods

Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped

We then matched census-block groups within the income groups by population density and percentage of minority representation

One matched block group per income level was randomly selected

Prevalence of Obesity in

Block-Groups

0

5

10

15

20

25

30

35

40

45

50

Ag

e-a

dju

sted

Ob

esit

y P

rev

ale

nce

(

)

High-Income Low-Income

Age-standardized to the 1990 US Census

Density of Environmental Factors in the

Community Contributes to a ldquoToxicrdquo

Obesity Environment

0

2

4

6

8

10

12

14

16

18

Fast-food Convenience Store Bars

Den

sity

10

00

perso

ns

High-Income Low-Income

COMMUNITYrsquoS PERCEPTION OF SAFETY

0

5

10

15

20

25

30

35

40

Daytime Nighttime

Perc

en

t (

) F

eeli

ng

So

mew

hat

Safe

or

Un

safe

Low-Income High-Income

Percent Substandard (or worse) Housing

or Ground Conditions

of Residential Properties

0

10

20

30

Structural Grounds

Perc

en

t (

)

Low-Income High-Income

CONCLUSIONS

These data suggest that the higher

frequency of outlets providing

calorically-dense foods and alcohol may

contribute to greater obesity prevalence

in residents of low-income communities

More research is needed to thoroughly

document environmental determinants

of health and obesity

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

From 1994-1998 HUD randomly assigned

4498 women with children living in public

housing in high-poverty urban census

tracts to one of three groups (1) housing

vouchers redeemable only if they moved

to a low-poverty census tract (2)

unrestricted vouchers or (3) control group

(no vouchers)

Ludwig et al NEJM 201136516

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

10-12 year follow-up showed modest but

potentially important reductions in the

prevalence of extreme obesity amp diabetes in the

group moving from a neighborhood with high

poverty on one of low poverty compared to the

control group

No differences between the group receiving

traditional vouchers amp the control group

ldquoNeighborhoods matterrdquo

Ludwig et al NEJM 201136516

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance traffic safety in areas where

persons are or could be physically active

--Community-scale urban design amp land use policies to

promote physical activity including design components

to improve street lighting infrastructure projects to

increase safety of pedestrian street crossing and use of

traffic calming approaches such as speed humps amp

traffic circles are effective in increasing physical activity

--Both community-scale amp street-scale policies amp practices

are effective in increasing physical activity

Recommended Community Strategies Encourage Communities to Organize for Change

Participate in community coalitions or

partnerships to address obesity

--Little evidence is available to determine the

impact of community coalitions on obesity

prevention

--The presence of anti-smoking community

coalitions has been associated with lower rates

of tobacco consumption

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

$103 million awarded to 61 states and

communities including state amp local government

agencies tribes amp territories amp state amp local non-

profit organizations

To build capacity to implement changes for

community prevention efforts to ensure long-

term success

To implement evidence-based and practice-

based programs to improve health amp wellness

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Priority areas are

Tobacco-free living

Active living and healthy eating

Evidence-based quality clinical and other

preventive health services for prevention

and control of high blood pressure and

high cholesterol

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Applicants proposed specific activities in

line with their chosen priority areas in their

applications

Grantee activities will not be finalized until

plans are negotiated with CDC by early

2012

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Capacity-Building Award

The Confederated Tribes of The Chehalis

Reservation is receiving a $498663 planning

award to build capacity to support healthy

lifestyles among their tribal population of 1500

in Washington State

Work will target tobacco-free living active living

and healthy eating and quality clinical and other

healthy serviceswwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Implementation Award

Austin TX Dept of Health and Human Services

is receiving $1026158 to serve Travis County

(Austin) to expand efforts in tobacco-free living

active living and healthy eating quality clinical

and other preventive services social and

emotional wellness and healthy and safe

physical environmentswwwcdcgov1052011

Building sustainable healthy

communities Bottom line

Obesity is an environmental problem

Despite progress in genetic research public health advances only will occur when we take the environment seriously

Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment

Until we do this we will not make substantial progress in addressing the epidemic of obesity

Poston amp Foreyt Atherosclerosis 1999

Whatrsquos the best approach

Integrate all sectors of society into community

change interventions

Incorporate

Science amp Technology

Education

FamilyCommunity

Healthcare

Arts amp Entertainment

Law amp Politics

Commerce amp Trade

Sectors of Society

Arts amp Entertainm

ent

Commerce amp Trade

Education

FamilyCommunity

Healthcare

Law amp Politics

Science amp Technology

Project FIT rationale design and baseline characteristics of a school- and community-

based intervention to address physical activity and healthy eating among low-income

elementary school children

Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D

Oh HJ Orth J Randall S Mayfield K Holmes D

Source

Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu

Abstract

BACKGROUND

This paper describes Project FIT a collaboration between the public school system local

health systems physicians neighborhood associations businesses faith-based leaders

community agencies and university researchers to develop a multi-faceted approach to

promote physical activity and healthy eating toward the general goal of preventing and

reducing childhood obesity among children in Grand Rapids MI USA

METHODSDESIGN

There are four overall components to Project FIT school community social marketing and

school staff wellness - all that focus on 1) increasing access to safe and affordable physical

activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)

improving the affordability and availability of nutritious food in the neighborhoods surrounding

the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding

nutrition and physical activity among school staff parents and students 4) impacting the

culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging

dialogue among all community partners to leverage existing programs and introduce new

ones

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Locating schools within easy walking

distance of residential areas

--Community-scale urban design amp land use policies amp

practices including locating schools stores workplaces

amp recreation areas close to residential areas are

effective in facilitating an increase in levels of physical

activity

--Majority of efforts to encourage walking to school involve

improving the routes rather than improving the location

of schools

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Improve access to public transportation

--Insufficient evidence exists to determine

effectiveness of transportation policies in

increasing the level of physical activity or

improving fitness

--1 study indicated that 29 of individuals who

walk to and from public transit achieve at least

30 minutes of daily physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Zone for mixed-use development

--Allows residential commercial institutional amp

other public land uses to be located in close

proximity to one another

--Studies using correlation analyses amp regression

models indicated that mixed land use was

associated with increased walking amp cycling

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance personal safety in areas where

persons are or could be physically active

--Cross-sectional studies have demonstrated a

negative relationship between crime rates andor

perceived safety amp physical activity in

neighborhoods

--Few intervention studies have evaluated the

impact of policies amp practices to improve

personal safety on physical activity

Geospatial Mapping Linking Urban

Environments to Health Risk

Measure association between environmental variables amp health risk factors

Assess relationships between variables at different levels of analysis

Used in conjunction with linear analyses

Our Community Environmental Model

of Obesity

Community Factors

Poverty

Crime

Grocery Quality

Restaurants

Parks

Sidewalks

Fast Food Outlets

Recreational

Facilities

Individual Factors

Dietary Intake

Physical Activity

Genetics

Family History

StressCoping

Eating Disorders

Psychological

Problems

Weight

Status

Chosen Neighborhoods

Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped

We then matched census-block groups within the income groups by population density and percentage of minority representation

One matched block group per income level was randomly selected

Prevalence of Obesity in

Block-Groups

0

5

10

15

20

25

30

35

40

45

50

Ag

e-a

dju

sted

Ob

esit

y P

rev

ale

nce

(

)

High-Income Low-Income

Age-standardized to the 1990 US Census

Density of Environmental Factors in the

Community Contributes to a ldquoToxicrdquo

Obesity Environment

0

2

4

6

8

10

12

14

16

18

Fast-food Convenience Store Bars

Den

sity

10

00

perso

ns

High-Income Low-Income

COMMUNITYrsquoS PERCEPTION OF SAFETY

0

5

10

15

20

25

30

35

40

Daytime Nighttime

Perc

en

t (

) F

eeli

ng

So

mew

hat

Safe

or

Un

safe

Low-Income High-Income

Percent Substandard (or worse) Housing

or Ground Conditions

of Residential Properties

0

10

20

30

Structural Grounds

Perc

en

t (

)

Low-Income High-Income

CONCLUSIONS

These data suggest that the higher

frequency of outlets providing

calorically-dense foods and alcohol may

contribute to greater obesity prevalence

in residents of low-income communities

More research is needed to thoroughly

document environmental determinants

of health and obesity

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

From 1994-1998 HUD randomly assigned

4498 women with children living in public

housing in high-poverty urban census

tracts to one of three groups (1) housing

vouchers redeemable only if they moved

to a low-poverty census tract (2)

unrestricted vouchers or (3) control group

(no vouchers)

Ludwig et al NEJM 201136516

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

10-12 year follow-up showed modest but

potentially important reductions in the

prevalence of extreme obesity amp diabetes in the

group moving from a neighborhood with high

poverty on one of low poverty compared to the

control group

No differences between the group receiving

traditional vouchers amp the control group

ldquoNeighborhoods matterrdquo

Ludwig et al NEJM 201136516

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance traffic safety in areas where

persons are or could be physically active

--Community-scale urban design amp land use policies to

promote physical activity including design components

to improve street lighting infrastructure projects to

increase safety of pedestrian street crossing and use of

traffic calming approaches such as speed humps amp

traffic circles are effective in increasing physical activity

--Both community-scale amp street-scale policies amp practices

are effective in increasing physical activity

Recommended Community Strategies Encourage Communities to Organize for Change

Participate in community coalitions or

partnerships to address obesity

--Little evidence is available to determine the

impact of community coalitions on obesity

prevention

--The presence of anti-smoking community

coalitions has been associated with lower rates

of tobacco consumption

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

$103 million awarded to 61 states and

communities including state amp local government

agencies tribes amp territories amp state amp local non-

profit organizations

To build capacity to implement changes for

community prevention efforts to ensure long-

term success

To implement evidence-based and practice-

based programs to improve health amp wellness

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Priority areas are

Tobacco-free living

Active living and healthy eating

Evidence-based quality clinical and other

preventive health services for prevention

and control of high blood pressure and

high cholesterol

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Applicants proposed specific activities in

line with their chosen priority areas in their

applications

Grantee activities will not be finalized until

plans are negotiated with CDC by early

2012

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Capacity-Building Award

The Confederated Tribes of The Chehalis

Reservation is receiving a $498663 planning

award to build capacity to support healthy

lifestyles among their tribal population of 1500

in Washington State

Work will target tobacco-free living active living

and healthy eating and quality clinical and other

healthy serviceswwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Implementation Award

Austin TX Dept of Health and Human Services

is receiving $1026158 to serve Travis County

(Austin) to expand efforts in tobacco-free living

active living and healthy eating quality clinical

and other preventive services social and

emotional wellness and healthy and safe

physical environmentswwwcdcgov1052011

Building sustainable healthy

communities Bottom line

Obesity is an environmental problem

Despite progress in genetic research public health advances only will occur when we take the environment seriously

Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment

Until we do this we will not make substantial progress in addressing the epidemic of obesity

Poston amp Foreyt Atherosclerosis 1999

Whatrsquos the best approach

Integrate all sectors of society into community

change interventions

Incorporate

Science amp Technology

Education

FamilyCommunity

Healthcare

Arts amp Entertainment

Law amp Politics

Commerce amp Trade

Sectors of Society

Arts amp Entertainm

ent

Commerce amp Trade

Education

FamilyCommunity

Healthcare

Law amp Politics

Science amp Technology

Project FIT rationale design and baseline characteristics of a school- and community-

based intervention to address physical activity and healthy eating among low-income

elementary school children

Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D

Oh HJ Orth J Randall S Mayfield K Holmes D

Source

Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu

Abstract

BACKGROUND

This paper describes Project FIT a collaboration between the public school system local

health systems physicians neighborhood associations businesses faith-based leaders

community agencies and university researchers to develop a multi-faceted approach to

promote physical activity and healthy eating toward the general goal of preventing and

reducing childhood obesity among children in Grand Rapids MI USA

METHODSDESIGN

There are four overall components to Project FIT school community social marketing and

school staff wellness - all that focus on 1) increasing access to safe and affordable physical

activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)

improving the affordability and availability of nutritious food in the neighborhoods surrounding

the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding

nutrition and physical activity among school staff parents and students 4) impacting the

culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging

dialogue among all community partners to leverage existing programs and introduce new

ones

Recommended Community Strategies Strategies to create safe communities that support

physical activity

Improve access to public transportation

--Insufficient evidence exists to determine

effectiveness of transportation policies in

increasing the level of physical activity or

improving fitness

--1 study indicated that 29 of individuals who

walk to and from public transit achieve at least

30 minutes of daily physical activity

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Zone for mixed-use development

--Allows residential commercial institutional amp

other public land uses to be located in close

proximity to one another

--Studies using correlation analyses amp regression

models indicated that mixed land use was

associated with increased walking amp cycling

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance personal safety in areas where

persons are or could be physically active

--Cross-sectional studies have demonstrated a

negative relationship between crime rates andor

perceived safety amp physical activity in

neighborhoods

--Few intervention studies have evaluated the

impact of policies amp practices to improve

personal safety on physical activity

Geospatial Mapping Linking Urban

Environments to Health Risk

Measure association between environmental variables amp health risk factors

Assess relationships between variables at different levels of analysis

Used in conjunction with linear analyses

Our Community Environmental Model

of Obesity

Community Factors

Poverty

Crime

Grocery Quality

Restaurants

Parks

Sidewalks

Fast Food Outlets

Recreational

Facilities

Individual Factors

Dietary Intake

Physical Activity

Genetics

Family History

StressCoping

Eating Disorders

Psychological

Problems

Weight

Status

Chosen Neighborhoods

Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped

We then matched census-block groups within the income groups by population density and percentage of minority representation

One matched block group per income level was randomly selected

Prevalence of Obesity in

Block-Groups

0

5

10

15

20

25

30

35

40

45

50

Ag

e-a

dju

sted

Ob

esit

y P

rev

ale

nce

(

)

High-Income Low-Income

Age-standardized to the 1990 US Census

Density of Environmental Factors in the

Community Contributes to a ldquoToxicrdquo

Obesity Environment

0

2

4

6

8

10

12

14

16

18

Fast-food Convenience Store Bars

Den

sity

10

00

perso

ns

High-Income Low-Income

COMMUNITYrsquoS PERCEPTION OF SAFETY

0

5

10

15

20

25

30

35

40

Daytime Nighttime

Perc

en

t (

) F

eeli

ng

So

mew

hat

Safe

or

Un

safe

Low-Income High-Income

Percent Substandard (or worse) Housing

or Ground Conditions

of Residential Properties

0

10

20

30

Structural Grounds

Perc

en

t (

)

Low-Income High-Income

CONCLUSIONS

These data suggest that the higher

frequency of outlets providing

calorically-dense foods and alcohol may

contribute to greater obesity prevalence

in residents of low-income communities

More research is needed to thoroughly

document environmental determinants

of health and obesity

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

From 1994-1998 HUD randomly assigned

4498 women with children living in public

housing in high-poverty urban census

tracts to one of three groups (1) housing

vouchers redeemable only if they moved

to a low-poverty census tract (2)

unrestricted vouchers or (3) control group

(no vouchers)

Ludwig et al NEJM 201136516

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

10-12 year follow-up showed modest but

potentially important reductions in the

prevalence of extreme obesity amp diabetes in the

group moving from a neighborhood with high

poverty on one of low poverty compared to the

control group

No differences between the group receiving

traditional vouchers amp the control group

ldquoNeighborhoods matterrdquo

Ludwig et al NEJM 201136516

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance traffic safety in areas where

persons are or could be physically active

--Community-scale urban design amp land use policies to

promote physical activity including design components

to improve street lighting infrastructure projects to

increase safety of pedestrian street crossing and use of

traffic calming approaches such as speed humps amp

traffic circles are effective in increasing physical activity

--Both community-scale amp street-scale policies amp practices

are effective in increasing physical activity

Recommended Community Strategies Encourage Communities to Organize for Change

Participate in community coalitions or

partnerships to address obesity

--Little evidence is available to determine the

impact of community coalitions on obesity

prevention

--The presence of anti-smoking community

coalitions has been associated with lower rates

of tobacco consumption

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

$103 million awarded to 61 states and

communities including state amp local government

agencies tribes amp territories amp state amp local non-

profit organizations

To build capacity to implement changes for

community prevention efforts to ensure long-

term success

To implement evidence-based and practice-

based programs to improve health amp wellness

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Priority areas are

Tobacco-free living

Active living and healthy eating

Evidence-based quality clinical and other

preventive health services for prevention

and control of high blood pressure and

high cholesterol

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Applicants proposed specific activities in

line with their chosen priority areas in their

applications

Grantee activities will not be finalized until

plans are negotiated with CDC by early

2012

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Capacity-Building Award

The Confederated Tribes of The Chehalis

Reservation is receiving a $498663 planning

award to build capacity to support healthy

lifestyles among their tribal population of 1500

in Washington State

Work will target tobacco-free living active living

and healthy eating and quality clinical and other

healthy serviceswwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Implementation Award

Austin TX Dept of Health and Human Services

is receiving $1026158 to serve Travis County

(Austin) to expand efforts in tobacco-free living

active living and healthy eating quality clinical

and other preventive services social and

emotional wellness and healthy and safe

physical environmentswwwcdcgov1052011

Building sustainable healthy

communities Bottom line

Obesity is an environmental problem

Despite progress in genetic research public health advances only will occur when we take the environment seriously

Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment

Until we do this we will not make substantial progress in addressing the epidemic of obesity

Poston amp Foreyt Atherosclerosis 1999

Whatrsquos the best approach

Integrate all sectors of society into community

change interventions

Incorporate

Science amp Technology

Education

FamilyCommunity

Healthcare

Arts amp Entertainment

Law amp Politics

Commerce amp Trade

Sectors of Society

Arts amp Entertainm

ent

Commerce amp Trade

Education

FamilyCommunity

Healthcare

Law amp Politics

Science amp Technology

Project FIT rationale design and baseline characteristics of a school- and community-

based intervention to address physical activity and healthy eating among low-income

elementary school children

Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D

Oh HJ Orth J Randall S Mayfield K Holmes D

Source

Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu

Abstract

BACKGROUND

This paper describes Project FIT a collaboration between the public school system local

health systems physicians neighborhood associations businesses faith-based leaders

community agencies and university researchers to develop a multi-faceted approach to

promote physical activity and healthy eating toward the general goal of preventing and

reducing childhood obesity among children in Grand Rapids MI USA

METHODSDESIGN

There are four overall components to Project FIT school community social marketing and

school staff wellness - all that focus on 1) increasing access to safe and affordable physical

activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)

improving the affordability and availability of nutritious food in the neighborhoods surrounding

the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding

nutrition and physical activity among school staff parents and students 4) impacting the

culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging

dialogue among all community partners to leverage existing programs and introduce new

ones

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Zone for mixed-use development

--Allows residential commercial institutional amp

other public land uses to be located in close

proximity to one another

--Studies using correlation analyses amp regression

models indicated that mixed land use was

associated with increased walking amp cycling

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance personal safety in areas where

persons are or could be physically active

--Cross-sectional studies have demonstrated a

negative relationship between crime rates andor

perceived safety amp physical activity in

neighborhoods

--Few intervention studies have evaluated the

impact of policies amp practices to improve

personal safety on physical activity

Geospatial Mapping Linking Urban

Environments to Health Risk

Measure association between environmental variables amp health risk factors

Assess relationships between variables at different levels of analysis

Used in conjunction with linear analyses

Our Community Environmental Model

of Obesity

Community Factors

Poverty

Crime

Grocery Quality

Restaurants

Parks

Sidewalks

Fast Food Outlets

Recreational

Facilities

Individual Factors

Dietary Intake

Physical Activity

Genetics

Family History

StressCoping

Eating Disorders

Psychological

Problems

Weight

Status

Chosen Neighborhoods

Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped

We then matched census-block groups within the income groups by population density and percentage of minority representation

One matched block group per income level was randomly selected

Prevalence of Obesity in

Block-Groups

0

5

10

15

20

25

30

35

40

45

50

Ag

e-a

dju

sted

Ob

esit

y P

rev

ale

nce

(

)

High-Income Low-Income

Age-standardized to the 1990 US Census

Density of Environmental Factors in the

Community Contributes to a ldquoToxicrdquo

Obesity Environment

0

2

4

6

8

10

12

14

16

18

Fast-food Convenience Store Bars

Den

sity

10

00

perso

ns

High-Income Low-Income

COMMUNITYrsquoS PERCEPTION OF SAFETY

0

5

10

15

20

25

30

35

40

Daytime Nighttime

Perc

en

t (

) F

eeli

ng

So

mew

hat

Safe

or

Un

safe

Low-Income High-Income

Percent Substandard (or worse) Housing

or Ground Conditions

of Residential Properties

0

10

20

30

Structural Grounds

Perc

en

t (

)

Low-Income High-Income

CONCLUSIONS

These data suggest that the higher

frequency of outlets providing

calorically-dense foods and alcohol may

contribute to greater obesity prevalence

in residents of low-income communities

More research is needed to thoroughly

document environmental determinants

of health and obesity

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

From 1994-1998 HUD randomly assigned

4498 women with children living in public

housing in high-poverty urban census

tracts to one of three groups (1) housing

vouchers redeemable only if they moved

to a low-poverty census tract (2)

unrestricted vouchers or (3) control group

(no vouchers)

Ludwig et al NEJM 201136516

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

10-12 year follow-up showed modest but

potentially important reductions in the

prevalence of extreme obesity amp diabetes in the

group moving from a neighborhood with high

poverty on one of low poverty compared to the

control group

No differences between the group receiving

traditional vouchers amp the control group

ldquoNeighborhoods matterrdquo

Ludwig et al NEJM 201136516

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance traffic safety in areas where

persons are or could be physically active

--Community-scale urban design amp land use policies to

promote physical activity including design components

to improve street lighting infrastructure projects to

increase safety of pedestrian street crossing and use of

traffic calming approaches such as speed humps amp

traffic circles are effective in increasing physical activity

--Both community-scale amp street-scale policies amp practices

are effective in increasing physical activity

Recommended Community Strategies Encourage Communities to Organize for Change

Participate in community coalitions or

partnerships to address obesity

--Little evidence is available to determine the

impact of community coalitions on obesity

prevention

--The presence of anti-smoking community

coalitions has been associated with lower rates

of tobacco consumption

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

$103 million awarded to 61 states and

communities including state amp local government

agencies tribes amp territories amp state amp local non-

profit organizations

To build capacity to implement changes for

community prevention efforts to ensure long-

term success

To implement evidence-based and practice-

based programs to improve health amp wellness

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Priority areas are

Tobacco-free living

Active living and healthy eating

Evidence-based quality clinical and other

preventive health services for prevention

and control of high blood pressure and

high cholesterol

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Applicants proposed specific activities in

line with their chosen priority areas in their

applications

Grantee activities will not be finalized until

plans are negotiated with CDC by early

2012

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Capacity-Building Award

The Confederated Tribes of The Chehalis

Reservation is receiving a $498663 planning

award to build capacity to support healthy

lifestyles among their tribal population of 1500

in Washington State

Work will target tobacco-free living active living

and healthy eating and quality clinical and other

healthy serviceswwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Implementation Award

Austin TX Dept of Health and Human Services

is receiving $1026158 to serve Travis County

(Austin) to expand efforts in tobacco-free living

active living and healthy eating quality clinical

and other preventive services social and

emotional wellness and healthy and safe

physical environmentswwwcdcgov1052011

Building sustainable healthy

communities Bottom line

Obesity is an environmental problem

Despite progress in genetic research public health advances only will occur when we take the environment seriously

Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment

Until we do this we will not make substantial progress in addressing the epidemic of obesity

Poston amp Foreyt Atherosclerosis 1999

Whatrsquos the best approach

Integrate all sectors of society into community

change interventions

Incorporate

Science amp Technology

Education

FamilyCommunity

Healthcare

Arts amp Entertainment

Law amp Politics

Commerce amp Trade

Sectors of Society

Arts amp Entertainm

ent

Commerce amp Trade

Education

FamilyCommunity

Healthcare

Law amp Politics

Science amp Technology

Project FIT rationale design and baseline characteristics of a school- and community-

based intervention to address physical activity and healthy eating among low-income

elementary school children

Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D

Oh HJ Orth J Randall S Mayfield K Holmes D

Source

Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu

Abstract

BACKGROUND

This paper describes Project FIT a collaboration between the public school system local

health systems physicians neighborhood associations businesses faith-based leaders

community agencies and university researchers to develop a multi-faceted approach to

promote physical activity and healthy eating toward the general goal of preventing and

reducing childhood obesity among children in Grand Rapids MI USA

METHODSDESIGN

There are four overall components to Project FIT school community social marketing and

school staff wellness - all that focus on 1) increasing access to safe and affordable physical

activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)

improving the affordability and availability of nutritious food in the neighborhoods surrounding

the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding

nutrition and physical activity among school staff parents and students 4) impacting the

culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging

dialogue among all community partners to leverage existing programs and introduce new

ones

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance personal safety in areas where

persons are or could be physically active

--Cross-sectional studies have demonstrated a

negative relationship between crime rates andor

perceived safety amp physical activity in

neighborhoods

--Few intervention studies have evaluated the

impact of policies amp practices to improve

personal safety on physical activity

Geospatial Mapping Linking Urban

Environments to Health Risk

Measure association between environmental variables amp health risk factors

Assess relationships between variables at different levels of analysis

Used in conjunction with linear analyses

Our Community Environmental Model

of Obesity

Community Factors

Poverty

Crime

Grocery Quality

Restaurants

Parks

Sidewalks

Fast Food Outlets

Recreational

Facilities

Individual Factors

Dietary Intake

Physical Activity

Genetics

Family History

StressCoping

Eating Disorders

Psychological

Problems

Weight

Status

Chosen Neighborhoods

Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped

We then matched census-block groups within the income groups by population density and percentage of minority representation

One matched block group per income level was randomly selected

Prevalence of Obesity in

Block-Groups

0

5

10

15

20

25

30

35

40

45

50

Ag

e-a

dju

sted

Ob

esit

y P

rev

ale

nce

(

)

High-Income Low-Income

Age-standardized to the 1990 US Census

Density of Environmental Factors in the

Community Contributes to a ldquoToxicrdquo

Obesity Environment

0

2

4

6

8

10

12

14

16

18

Fast-food Convenience Store Bars

Den

sity

10

00

perso

ns

High-Income Low-Income

COMMUNITYrsquoS PERCEPTION OF SAFETY

0

5

10

15

20

25

30

35

40

Daytime Nighttime

Perc

en

t (

) F

eeli

ng

So

mew

hat

Safe

or

Un

safe

Low-Income High-Income

Percent Substandard (or worse) Housing

or Ground Conditions

of Residential Properties

0

10

20

30

Structural Grounds

Perc

en

t (

)

Low-Income High-Income

CONCLUSIONS

These data suggest that the higher

frequency of outlets providing

calorically-dense foods and alcohol may

contribute to greater obesity prevalence

in residents of low-income communities

More research is needed to thoroughly

document environmental determinants

of health and obesity

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

From 1994-1998 HUD randomly assigned

4498 women with children living in public

housing in high-poverty urban census

tracts to one of three groups (1) housing

vouchers redeemable only if they moved

to a low-poverty census tract (2)

unrestricted vouchers or (3) control group

(no vouchers)

Ludwig et al NEJM 201136516

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

10-12 year follow-up showed modest but

potentially important reductions in the

prevalence of extreme obesity amp diabetes in the

group moving from a neighborhood with high

poverty on one of low poverty compared to the

control group

No differences between the group receiving

traditional vouchers amp the control group

ldquoNeighborhoods matterrdquo

Ludwig et al NEJM 201136516

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance traffic safety in areas where

persons are or could be physically active

--Community-scale urban design amp land use policies to

promote physical activity including design components

to improve street lighting infrastructure projects to

increase safety of pedestrian street crossing and use of

traffic calming approaches such as speed humps amp

traffic circles are effective in increasing physical activity

--Both community-scale amp street-scale policies amp practices

are effective in increasing physical activity

Recommended Community Strategies Encourage Communities to Organize for Change

Participate in community coalitions or

partnerships to address obesity

--Little evidence is available to determine the

impact of community coalitions on obesity

prevention

--The presence of anti-smoking community

coalitions has been associated with lower rates

of tobacco consumption

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

$103 million awarded to 61 states and

communities including state amp local government

agencies tribes amp territories amp state amp local non-

profit organizations

To build capacity to implement changes for

community prevention efforts to ensure long-

term success

To implement evidence-based and practice-

based programs to improve health amp wellness

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Priority areas are

Tobacco-free living

Active living and healthy eating

Evidence-based quality clinical and other

preventive health services for prevention

and control of high blood pressure and

high cholesterol

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Applicants proposed specific activities in

line with their chosen priority areas in their

applications

Grantee activities will not be finalized until

plans are negotiated with CDC by early

2012

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Capacity-Building Award

The Confederated Tribes of The Chehalis

Reservation is receiving a $498663 planning

award to build capacity to support healthy

lifestyles among their tribal population of 1500

in Washington State

Work will target tobacco-free living active living

and healthy eating and quality clinical and other

healthy serviceswwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Implementation Award

Austin TX Dept of Health and Human Services

is receiving $1026158 to serve Travis County

(Austin) to expand efforts in tobacco-free living

active living and healthy eating quality clinical

and other preventive services social and

emotional wellness and healthy and safe

physical environmentswwwcdcgov1052011

Building sustainable healthy

communities Bottom line

Obesity is an environmental problem

Despite progress in genetic research public health advances only will occur when we take the environment seriously

Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment

Until we do this we will not make substantial progress in addressing the epidemic of obesity

Poston amp Foreyt Atherosclerosis 1999

Whatrsquos the best approach

Integrate all sectors of society into community

change interventions

Incorporate

Science amp Technology

Education

FamilyCommunity

Healthcare

Arts amp Entertainment

Law amp Politics

Commerce amp Trade

Sectors of Society

Arts amp Entertainm

ent

Commerce amp Trade

Education

FamilyCommunity

Healthcare

Law amp Politics

Science amp Technology

Project FIT rationale design and baseline characteristics of a school- and community-

based intervention to address physical activity and healthy eating among low-income

elementary school children

Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D

Oh HJ Orth J Randall S Mayfield K Holmes D

Source

Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu

Abstract

BACKGROUND

This paper describes Project FIT a collaboration between the public school system local

health systems physicians neighborhood associations businesses faith-based leaders

community agencies and university researchers to develop a multi-faceted approach to

promote physical activity and healthy eating toward the general goal of preventing and

reducing childhood obesity among children in Grand Rapids MI USA

METHODSDESIGN

There are four overall components to Project FIT school community social marketing and

school staff wellness - all that focus on 1) increasing access to safe and affordable physical

activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)

improving the affordability and availability of nutritious food in the neighborhoods surrounding

the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding

nutrition and physical activity among school staff parents and students 4) impacting the

culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging

dialogue among all community partners to leverage existing programs and introduce new

ones

Geospatial Mapping Linking Urban

Environments to Health Risk

Measure association between environmental variables amp health risk factors

Assess relationships between variables at different levels of analysis

Used in conjunction with linear analyses

Our Community Environmental Model

of Obesity

Community Factors

Poverty

Crime

Grocery Quality

Restaurants

Parks

Sidewalks

Fast Food Outlets

Recreational

Facilities

Individual Factors

Dietary Intake

Physical Activity

Genetics

Family History

StressCoping

Eating Disorders

Psychological

Problems

Weight

Status

Chosen Neighborhoods

Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped

We then matched census-block groups within the income groups by population density and percentage of minority representation

One matched block group per income level was randomly selected

Prevalence of Obesity in

Block-Groups

0

5

10

15

20

25

30

35

40

45

50

Ag

e-a

dju

sted

Ob

esit

y P

rev

ale

nce

(

)

High-Income Low-Income

Age-standardized to the 1990 US Census

Density of Environmental Factors in the

Community Contributes to a ldquoToxicrdquo

Obesity Environment

0

2

4

6

8

10

12

14

16

18

Fast-food Convenience Store Bars

Den

sity

10

00

perso

ns

High-Income Low-Income

COMMUNITYrsquoS PERCEPTION OF SAFETY

0

5

10

15

20

25

30

35

40

Daytime Nighttime

Perc

en

t (

) F

eeli

ng

So

mew

hat

Safe

or

Un

safe

Low-Income High-Income

Percent Substandard (or worse) Housing

or Ground Conditions

of Residential Properties

0

10

20

30

Structural Grounds

Perc

en

t (

)

Low-Income High-Income

CONCLUSIONS

These data suggest that the higher

frequency of outlets providing

calorically-dense foods and alcohol may

contribute to greater obesity prevalence

in residents of low-income communities

More research is needed to thoroughly

document environmental determinants

of health and obesity

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

From 1994-1998 HUD randomly assigned

4498 women with children living in public

housing in high-poverty urban census

tracts to one of three groups (1) housing

vouchers redeemable only if they moved

to a low-poverty census tract (2)

unrestricted vouchers or (3) control group

(no vouchers)

Ludwig et al NEJM 201136516

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

10-12 year follow-up showed modest but

potentially important reductions in the

prevalence of extreme obesity amp diabetes in the

group moving from a neighborhood with high

poverty on one of low poverty compared to the

control group

No differences between the group receiving

traditional vouchers amp the control group

ldquoNeighborhoods matterrdquo

Ludwig et al NEJM 201136516

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance traffic safety in areas where

persons are or could be physically active

--Community-scale urban design amp land use policies to

promote physical activity including design components

to improve street lighting infrastructure projects to

increase safety of pedestrian street crossing and use of

traffic calming approaches such as speed humps amp

traffic circles are effective in increasing physical activity

--Both community-scale amp street-scale policies amp practices

are effective in increasing physical activity

Recommended Community Strategies Encourage Communities to Organize for Change

Participate in community coalitions or

partnerships to address obesity

--Little evidence is available to determine the

impact of community coalitions on obesity

prevention

--The presence of anti-smoking community

coalitions has been associated with lower rates

of tobacco consumption

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

$103 million awarded to 61 states and

communities including state amp local government

agencies tribes amp territories amp state amp local non-

profit organizations

To build capacity to implement changes for

community prevention efforts to ensure long-

term success

To implement evidence-based and practice-

based programs to improve health amp wellness

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Priority areas are

Tobacco-free living

Active living and healthy eating

Evidence-based quality clinical and other

preventive health services for prevention

and control of high blood pressure and

high cholesterol

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Applicants proposed specific activities in

line with their chosen priority areas in their

applications

Grantee activities will not be finalized until

plans are negotiated with CDC by early

2012

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Capacity-Building Award

The Confederated Tribes of The Chehalis

Reservation is receiving a $498663 planning

award to build capacity to support healthy

lifestyles among their tribal population of 1500

in Washington State

Work will target tobacco-free living active living

and healthy eating and quality clinical and other

healthy serviceswwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Implementation Award

Austin TX Dept of Health and Human Services

is receiving $1026158 to serve Travis County

(Austin) to expand efforts in tobacco-free living

active living and healthy eating quality clinical

and other preventive services social and

emotional wellness and healthy and safe

physical environmentswwwcdcgov1052011

Building sustainable healthy

communities Bottom line

Obesity is an environmental problem

Despite progress in genetic research public health advances only will occur when we take the environment seriously

Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment

Until we do this we will not make substantial progress in addressing the epidemic of obesity

Poston amp Foreyt Atherosclerosis 1999

Whatrsquos the best approach

Integrate all sectors of society into community

change interventions

Incorporate

Science amp Technology

Education

FamilyCommunity

Healthcare

Arts amp Entertainment

Law amp Politics

Commerce amp Trade

Sectors of Society

Arts amp Entertainm

ent

Commerce amp Trade

Education

FamilyCommunity

Healthcare

Law amp Politics

Science amp Technology

Project FIT rationale design and baseline characteristics of a school- and community-

based intervention to address physical activity and healthy eating among low-income

elementary school children

Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D

Oh HJ Orth J Randall S Mayfield K Holmes D

Source

Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu

Abstract

BACKGROUND

This paper describes Project FIT a collaboration between the public school system local

health systems physicians neighborhood associations businesses faith-based leaders

community agencies and university researchers to develop a multi-faceted approach to

promote physical activity and healthy eating toward the general goal of preventing and

reducing childhood obesity among children in Grand Rapids MI USA

METHODSDESIGN

There are four overall components to Project FIT school community social marketing and

school staff wellness - all that focus on 1) increasing access to safe and affordable physical

activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)

improving the affordability and availability of nutritious food in the neighborhoods surrounding

the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding

nutrition and physical activity among school staff parents and students 4) impacting the

culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging

dialogue among all community partners to leverage existing programs and introduce new

ones

Our Community Environmental Model

of Obesity

Community Factors

Poverty

Crime

Grocery Quality

Restaurants

Parks

Sidewalks

Fast Food Outlets

Recreational

Facilities

Individual Factors

Dietary Intake

Physical Activity

Genetics

Family History

StressCoping

Eating Disorders

Psychological

Problems

Weight

Status

Chosen Neighborhoods

Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped

We then matched census-block groups within the income groups by population density and percentage of minority representation

One matched block group per income level was randomly selected

Prevalence of Obesity in

Block-Groups

0

5

10

15

20

25

30

35

40

45

50

Ag

e-a

dju

sted

Ob

esit

y P

rev

ale

nce

(

)

High-Income Low-Income

Age-standardized to the 1990 US Census

Density of Environmental Factors in the

Community Contributes to a ldquoToxicrdquo

Obesity Environment

0

2

4

6

8

10

12

14

16

18

Fast-food Convenience Store Bars

Den

sity

10

00

perso

ns

High-Income Low-Income

COMMUNITYrsquoS PERCEPTION OF SAFETY

0

5

10

15

20

25

30

35

40

Daytime Nighttime

Perc

en

t (

) F

eeli

ng

So

mew

hat

Safe

or

Un

safe

Low-Income High-Income

Percent Substandard (or worse) Housing

or Ground Conditions

of Residential Properties

0

10

20

30

Structural Grounds

Perc

en

t (

)

Low-Income High-Income

CONCLUSIONS

These data suggest that the higher

frequency of outlets providing

calorically-dense foods and alcohol may

contribute to greater obesity prevalence

in residents of low-income communities

More research is needed to thoroughly

document environmental determinants

of health and obesity

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

From 1994-1998 HUD randomly assigned

4498 women with children living in public

housing in high-poverty urban census

tracts to one of three groups (1) housing

vouchers redeemable only if they moved

to a low-poverty census tract (2)

unrestricted vouchers or (3) control group

(no vouchers)

Ludwig et al NEJM 201136516

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

10-12 year follow-up showed modest but

potentially important reductions in the

prevalence of extreme obesity amp diabetes in the

group moving from a neighborhood with high

poverty on one of low poverty compared to the

control group

No differences between the group receiving

traditional vouchers amp the control group

ldquoNeighborhoods matterrdquo

Ludwig et al NEJM 201136516

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance traffic safety in areas where

persons are or could be physically active

--Community-scale urban design amp land use policies to

promote physical activity including design components

to improve street lighting infrastructure projects to

increase safety of pedestrian street crossing and use of

traffic calming approaches such as speed humps amp

traffic circles are effective in increasing physical activity

--Both community-scale amp street-scale policies amp practices

are effective in increasing physical activity

Recommended Community Strategies Encourage Communities to Organize for Change

Participate in community coalitions or

partnerships to address obesity

--Little evidence is available to determine the

impact of community coalitions on obesity

prevention

--The presence of anti-smoking community

coalitions has been associated with lower rates

of tobacco consumption

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

$103 million awarded to 61 states and

communities including state amp local government

agencies tribes amp territories amp state amp local non-

profit organizations

To build capacity to implement changes for

community prevention efforts to ensure long-

term success

To implement evidence-based and practice-

based programs to improve health amp wellness

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Priority areas are

Tobacco-free living

Active living and healthy eating

Evidence-based quality clinical and other

preventive health services for prevention

and control of high blood pressure and

high cholesterol

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Applicants proposed specific activities in

line with their chosen priority areas in their

applications

Grantee activities will not be finalized until

plans are negotiated with CDC by early

2012

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Capacity-Building Award

The Confederated Tribes of The Chehalis

Reservation is receiving a $498663 planning

award to build capacity to support healthy

lifestyles among their tribal population of 1500

in Washington State

Work will target tobacco-free living active living

and healthy eating and quality clinical and other

healthy serviceswwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Implementation Award

Austin TX Dept of Health and Human Services

is receiving $1026158 to serve Travis County

(Austin) to expand efforts in tobacco-free living

active living and healthy eating quality clinical

and other preventive services social and

emotional wellness and healthy and safe

physical environmentswwwcdcgov1052011

Building sustainable healthy

communities Bottom line

Obesity is an environmental problem

Despite progress in genetic research public health advances only will occur when we take the environment seriously

Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment

Until we do this we will not make substantial progress in addressing the epidemic of obesity

Poston amp Foreyt Atherosclerosis 1999

Whatrsquos the best approach

Integrate all sectors of society into community

change interventions

Incorporate

Science amp Technology

Education

FamilyCommunity

Healthcare

Arts amp Entertainment

Law amp Politics

Commerce amp Trade

Sectors of Society

Arts amp Entertainm

ent

Commerce amp Trade

Education

FamilyCommunity

Healthcare

Law amp Politics

Science amp Technology

Project FIT rationale design and baseline characteristics of a school- and community-

based intervention to address physical activity and healthy eating among low-income

elementary school children

Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D

Oh HJ Orth J Randall S Mayfield K Holmes D

Source

Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu

Abstract

BACKGROUND

This paper describes Project FIT a collaboration between the public school system local

health systems physicians neighborhood associations businesses faith-based leaders

community agencies and university researchers to develop a multi-faceted approach to

promote physical activity and healthy eating toward the general goal of preventing and

reducing childhood obesity among children in Grand Rapids MI USA

METHODSDESIGN

There are four overall components to Project FIT school community social marketing and

school staff wellness - all that focus on 1) increasing access to safe and affordable physical

activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)

improving the affordability and availability of nutritious food in the neighborhoods surrounding

the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding

nutrition and physical activity among school staff parents and students 4) impacting the

culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging

dialogue among all community partners to leverage existing programs and introduce new

ones

Chosen Neighborhoods

Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped

We then matched census-block groups within the income groups by population density and percentage of minority representation

One matched block group per income level was randomly selected

Prevalence of Obesity in

Block-Groups

0

5

10

15

20

25

30

35

40

45

50

Ag

e-a

dju

sted

Ob

esit

y P

rev

ale

nce

(

)

High-Income Low-Income

Age-standardized to the 1990 US Census

Density of Environmental Factors in the

Community Contributes to a ldquoToxicrdquo

Obesity Environment

0

2

4

6

8

10

12

14

16

18

Fast-food Convenience Store Bars

Den

sity

10

00

perso

ns

High-Income Low-Income

COMMUNITYrsquoS PERCEPTION OF SAFETY

0

5

10

15

20

25

30

35

40

Daytime Nighttime

Perc

en

t (

) F

eeli

ng

So

mew

hat

Safe

or

Un

safe

Low-Income High-Income

Percent Substandard (or worse) Housing

or Ground Conditions

of Residential Properties

0

10

20

30

Structural Grounds

Perc

en

t (

)

Low-Income High-Income

CONCLUSIONS

These data suggest that the higher

frequency of outlets providing

calorically-dense foods and alcohol may

contribute to greater obesity prevalence

in residents of low-income communities

More research is needed to thoroughly

document environmental determinants

of health and obesity

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

From 1994-1998 HUD randomly assigned

4498 women with children living in public

housing in high-poverty urban census

tracts to one of three groups (1) housing

vouchers redeemable only if they moved

to a low-poverty census tract (2)

unrestricted vouchers or (3) control group

(no vouchers)

Ludwig et al NEJM 201136516

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

10-12 year follow-up showed modest but

potentially important reductions in the

prevalence of extreme obesity amp diabetes in the

group moving from a neighborhood with high

poverty on one of low poverty compared to the

control group

No differences between the group receiving

traditional vouchers amp the control group

ldquoNeighborhoods matterrdquo

Ludwig et al NEJM 201136516

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance traffic safety in areas where

persons are or could be physically active

--Community-scale urban design amp land use policies to

promote physical activity including design components

to improve street lighting infrastructure projects to

increase safety of pedestrian street crossing and use of

traffic calming approaches such as speed humps amp

traffic circles are effective in increasing physical activity

--Both community-scale amp street-scale policies amp practices

are effective in increasing physical activity

Recommended Community Strategies Encourage Communities to Organize for Change

Participate in community coalitions or

partnerships to address obesity

--Little evidence is available to determine the

impact of community coalitions on obesity

prevention

--The presence of anti-smoking community

coalitions has been associated with lower rates

of tobacco consumption

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

$103 million awarded to 61 states and

communities including state amp local government

agencies tribes amp territories amp state amp local non-

profit organizations

To build capacity to implement changes for

community prevention efforts to ensure long-

term success

To implement evidence-based and practice-

based programs to improve health amp wellness

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Priority areas are

Tobacco-free living

Active living and healthy eating

Evidence-based quality clinical and other

preventive health services for prevention

and control of high blood pressure and

high cholesterol

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Applicants proposed specific activities in

line with their chosen priority areas in their

applications

Grantee activities will not be finalized until

plans are negotiated with CDC by early

2012

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Capacity-Building Award

The Confederated Tribes of The Chehalis

Reservation is receiving a $498663 planning

award to build capacity to support healthy

lifestyles among their tribal population of 1500

in Washington State

Work will target tobacco-free living active living

and healthy eating and quality clinical and other

healthy serviceswwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Implementation Award

Austin TX Dept of Health and Human Services

is receiving $1026158 to serve Travis County

(Austin) to expand efforts in tobacco-free living

active living and healthy eating quality clinical

and other preventive services social and

emotional wellness and healthy and safe

physical environmentswwwcdcgov1052011

Building sustainable healthy

communities Bottom line

Obesity is an environmental problem

Despite progress in genetic research public health advances only will occur when we take the environment seriously

Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment

Until we do this we will not make substantial progress in addressing the epidemic of obesity

Poston amp Foreyt Atherosclerosis 1999

Whatrsquos the best approach

Integrate all sectors of society into community

change interventions

Incorporate

Science amp Technology

Education

FamilyCommunity

Healthcare

Arts amp Entertainment

Law amp Politics

Commerce amp Trade

Sectors of Society

Arts amp Entertainm

ent

Commerce amp Trade

Education

FamilyCommunity

Healthcare

Law amp Politics

Science amp Technology

Project FIT rationale design and baseline characteristics of a school- and community-

based intervention to address physical activity and healthy eating among low-income

elementary school children

Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D

Oh HJ Orth J Randall S Mayfield K Holmes D

Source

Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu

Abstract

BACKGROUND

This paper describes Project FIT a collaboration between the public school system local

health systems physicians neighborhood associations businesses faith-based leaders

community agencies and university researchers to develop a multi-faceted approach to

promote physical activity and healthy eating toward the general goal of preventing and

reducing childhood obesity among children in Grand Rapids MI USA

METHODSDESIGN

There are four overall components to Project FIT school community social marketing and

school staff wellness - all that focus on 1) increasing access to safe and affordable physical

activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)

improving the affordability and availability of nutritious food in the neighborhoods surrounding

the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding

nutrition and physical activity among school staff parents and students 4) impacting the

culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging

dialogue among all community partners to leverage existing programs and introduce new

ones

Prevalence of Obesity in

Block-Groups

0

5

10

15

20

25

30

35

40

45

50

Ag

e-a

dju

sted

Ob

esit

y P

rev

ale

nce

(

)

High-Income Low-Income

Age-standardized to the 1990 US Census

Density of Environmental Factors in the

Community Contributes to a ldquoToxicrdquo

Obesity Environment

0

2

4

6

8

10

12

14

16

18

Fast-food Convenience Store Bars

Den

sity

10

00

perso

ns

High-Income Low-Income

COMMUNITYrsquoS PERCEPTION OF SAFETY

0

5

10

15

20

25

30

35

40

Daytime Nighttime

Perc

en

t (

) F

eeli

ng

So

mew

hat

Safe

or

Un

safe

Low-Income High-Income

Percent Substandard (or worse) Housing

or Ground Conditions

of Residential Properties

0

10

20

30

Structural Grounds

Perc

en

t (

)

Low-Income High-Income

CONCLUSIONS

These data suggest that the higher

frequency of outlets providing

calorically-dense foods and alcohol may

contribute to greater obesity prevalence

in residents of low-income communities

More research is needed to thoroughly

document environmental determinants

of health and obesity

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

From 1994-1998 HUD randomly assigned

4498 women with children living in public

housing in high-poverty urban census

tracts to one of three groups (1) housing

vouchers redeemable only if they moved

to a low-poverty census tract (2)

unrestricted vouchers or (3) control group

(no vouchers)

Ludwig et al NEJM 201136516

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

10-12 year follow-up showed modest but

potentially important reductions in the

prevalence of extreme obesity amp diabetes in the

group moving from a neighborhood with high

poverty on one of low poverty compared to the

control group

No differences between the group receiving

traditional vouchers amp the control group

ldquoNeighborhoods matterrdquo

Ludwig et al NEJM 201136516

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance traffic safety in areas where

persons are or could be physically active

--Community-scale urban design amp land use policies to

promote physical activity including design components

to improve street lighting infrastructure projects to

increase safety of pedestrian street crossing and use of

traffic calming approaches such as speed humps amp

traffic circles are effective in increasing physical activity

--Both community-scale amp street-scale policies amp practices

are effective in increasing physical activity

Recommended Community Strategies Encourage Communities to Organize for Change

Participate in community coalitions or

partnerships to address obesity

--Little evidence is available to determine the

impact of community coalitions on obesity

prevention

--The presence of anti-smoking community

coalitions has been associated with lower rates

of tobacco consumption

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

$103 million awarded to 61 states and

communities including state amp local government

agencies tribes amp territories amp state amp local non-

profit organizations

To build capacity to implement changes for

community prevention efforts to ensure long-

term success

To implement evidence-based and practice-

based programs to improve health amp wellness

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Priority areas are

Tobacco-free living

Active living and healthy eating

Evidence-based quality clinical and other

preventive health services for prevention

and control of high blood pressure and

high cholesterol

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Applicants proposed specific activities in

line with their chosen priority areas in their

applications

Grantee activities will not be finalized until

plans are negotiated with CDC by early

2012

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Capacity-Building Award

The Confederated Tribes of The Chehalis

Reservation is receiving a $498663 planning

award to build capacity to support healthy

lifestyles among their tribal population of 1500

in Washington State

Work will target tobacco-free living active living

and healthy eating and quality clinical and other

healthy serviceswwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Implementation Award

Austin TX Dept of Health and Human Services

is receiving $1026158 to serve Travis County

(Austin) to expand efforts in tobacco-free living

active living and healthy eating quality clinical

and other preventive services social and

emotional wellness and healthy and safe

physical environmentswwwcdcgov1052011

Building sustainable healthy

communities Bottom line

Obesity is an environmental problem

Despite progress in genetic research public health advances only will occur when we take the environment seriously

Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment

Until we do this we will not make substantial progress in addressing the epidemic of obesity

Poston amp Foreyt Atherosclerosis 1999

Whatrsquos the best approach

Integrate all sectors of society into community

change interventions

Incorporate

Science amp Technology

Education

FamilyCommunity

Healthcare

Arts amp Entertainment

Law amp Politics

Commerce amp Trade

Sectors of Society

Arts amp Entertainm

ent

Commerce amp Trade

Education

FamilyCommunity

Healthcare

Law amp Politics

Science amp Technology

Project FIT rationale design and baseline characteristics of a school- and community-

based intervention to address physical activity and healthy eating among low-income

elementary school children

Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D

Oh HJ Orth J Randall S Mayfield K Holmes D

Source

Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu

Abstract

BACKGROUND

This paper describes Project FIT a collaboration between the public school system local

health systems physicians neighborhood associations businesses faith-based leaders

community agencies and university researchers to develop a multi-faceted approach to

promote physical activity and healthy eating toward the general goal of preventing and

reducing childhood obesity among children in Grand Rapids MI USA

METHODSDESIGN

There are four overall components to Project FIT school community social marketing and

school staff wellness - all that focus on 1) increasing access to safe and affordable physical

activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)

improving the affordability and availability of nutritious food in the neighborhoods surrounding

the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding

nutrition and physical activity among school staff parents and students 4) impacting the

culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging

dialogue among all community partners to leverage existing programs and introduce new

ones

Density of Environmental Factors in the

Community Contributes to a ldquoToxicrdquo

Obesity Environment

0

2

4

6

8

10

12

14

16

18

Fast-food Convenience Store Bars

Den

sity

10

00

perso

ns

High-Income Low-Income

COMMUNITYrsquoS PERCEPTION OF SAFETY

0

5

10

15

20

25

30

35

40

Daytime Nighttime

Perc

en

t (

) F

eeli

ng

So

mew

hat

Safe

or

Un

safe

Low-Income High-Income

Percent Substandard (or worse) Housing

or Ground Conditions

of Residential Properties

0

10

20

30

Structural Grounds

Perc

en

t (

)

Low-Income High-Income

CONCLUSIONS

These data suggest that the higher

frequency of outlets providing

calorically-dense foods and alcohol may

contribute to greater obesity prevalence

in residents of low-income communities

More research is needed to thoroughly

document environmental determinants

of health and obesity

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

From 1994-1998 HUD randomly assigned

4498 women with children living in public

housing in high-poverty urban census

tracts to one of three groups (1) housing

vouchers redeemable only if they moved

to a low-poverty census tract (2)

unrestricted vouchers or (3) control group

(no vouchers)

Ludwig et al NEJM 201136516

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

10-12 year follow-up showed modest but

potentially important reductions in the

prevalence of extreme obesity amp diabetes in the

group moving from a neighborhood with high

poverty on one of low poverty compared to the

control group

No differences between the group receiving

traditional vouchers amp the control group

ldquoNeighborhoods matterrdquo

Ludwig et al NEJM 201136516

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance traffic safety in areas where

persons are or could be physically active

--Community-scale urban design amp land use policies to

promote physical activity including design components

to improve street lighting infrastructure projects to

increase safety of pedestrian street crossing and use of

traffic calming approaches such as speed humps amp

traffic circles are effective in increasing physical activity

--Both community-scale amp street-scale policies amp practices

are effective in increasing physical activity

Recommended Community Strategies Encourage Communities to Organize for Change

Participate in community coalitions or

partnerships to address obesity

--Little evidence is available to determine the

impact of community coalitions on obesity

prevention

--The presence of anti-smoking community

coalitions has been associated with lower rates

of tobacco consumption

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

$103 million awarded to 61 states and

communities including state amp local government

agencies tribes amp territories amp state amp local non-

profit organizations

To build capacity to implement changes for

community prevention efforts to ensure long-

term success

To implement evidence-based and practice-

based programs to improve health amp wellness

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Priority areas are

Tobacco-free living

Active living and healthy eating

Evidence-based quality clinical and other

preventive health services for prevention

and control of high blood pressure and

high cholesterol

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Applicants proposed specific activities in

line with their chosen priority areas in their

applications

Grantee activities will not be finalized until

plans are negotiated with CDC by early

2012

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Capacity-Building Award

The Confederated Tribes of The Chehalis

Reservation is receiving a $498663 planning

award to build capacity to support healthy

lifestyles among their tribal population of 1500

in Washington State

Work will target tobacco-free living active living

and healthy eating and quality clinical and other

healthy serviceswwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Implementation Award

Austin TX Dept of Health and Human Services

is receiving $1026158 to serve Travis County

(Austin) to expand efforts in tobacco-free living

active living and healthy eating quality clinical

and other preventive services social and

emotional wellness and healthy and safe

physical environmentswwwcdcgov1052011

Building sustainable healthy

communities Bottom line

Obesity is an environmental problem

Despite progress in genetic research public health advances only will occur when we take the environment seriously

Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment

Until we do this we will not make substantial progress in addressing the epidemic of obesity

Poston amp Foreyt Atherosclerosis 1999

Whatrsquos the best approach

Integrate all sectors of society into community

change interventions

Incorporate

Science amp Technology

Education

FamilyCommunity

Healthcare

Arts amp Entertainment

Law amp Politics

Commerce amp Trade

Sectors of Society

Arts amp Entertainm

ent

Commerce amp Trade

Education

FamilyCommunity

Healthcare

Law amp Politics

Science amp Technology

Project FIT rationale design and baseline characteristics of a school- and community-

based intervention to address physical activity and healthy eating among low-income

elementary school children

Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D

Oh HJ Orth J Randall S Mayfield K Holmes D

Source

Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu

Abstract

BACKGROUND

This paper describes Project FIT a collaboration between the public school system local

health systems physicians neighborhood associations businesses faith-based leaders

community agencies and university researchers to develop a multi-faceted approach to

promote physical activity and healthy eating toward the general goal of preventing and

reducing childhood obesity among children in Grand Rapids MI USA

METHODSDESIGN

There are four overall components to Project FIT school community social marketing and

school staff wellness - all that focus on 1) increasing access to safe and affordable physical

activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)

improving the affordability and availability of nutritious food in the neighborhoods surrounding

the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding

nutrition and physical activity among school staff parents and students 4) impacting the

culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging

dialogue among all community partners to leverage existing programs and introduce new

ones

COMMUNITYrsquoS PERCEPTION OF SAFETY

0

5

10

15

20

25

30

35

40

Daytime Nighttime

Perc

en

t (

) F

eeli

ng

So

mew

hat

Safe

or

Un

safe

Low-Income High-Income

Percent Substandard (or worse) Housing

or Ground Conditions

of Residential Properties

0

10

20

30

Structural Grounds

Perc

en

t (

)

Low-Income High-Income

CONCLUSIONS

These data suggest that the higher

frequency of outlets providing

calorically-dense foods and alcohol may

contribute to greater obesity prevalence

in residents of low-income communities

More research is needed to thoroughly

document environmental determinants

of health and obesity

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

From 1994-1998 HUD randomly assigned

4498 women with children living in public

housing in high-poverty urban census

tracts to one of three groups (1) housing

vouchers redeemable only if they moved

to a low-poverty census tract (2)

unrestricted vouchers or (3) control group

(no vouchers)

Ludwig et al NEJM 201136516

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

10-12 year follow-up showed modest but

potentially important reductions in the

prevalence of extreme obesity amp diabetes in the

group moving from a neighborhood with high

poverty on one of low poverty compared to the

control group

No differences between the group receiving

traditional vouchers amp the control group

ldquoNeighborhoods matterrdquo

Ludwig et al NEJM 201136516

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance traffic safety in areas where

persons are or could be physically active

--Community-scale urban design amp land use policies to

promote physical activity including design components

to improve street lighting infrastructure projects to

increase safety of pedestrian street crossing and use of

traffic calming approaches such as speed humps amp

traffic circles are effective in increasing physical activity

--Both community-scale amp street-scale policies amp practices

are effective in increasing physical activity

Recommended Community Strategies Encourage Communities to Organize for Change

Participate in community coalitions or

partnerships to address obesity

--Little evidence is available to determine the

impact of community coalitions on obesity

prevention

--The presence of anti-smoking community

coalitions has been associated with lower rates

of tobacco consumption

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

$103 million awarded to 61 states and

communities including state amp local government

agencies tribes amp territories amp state amp local non-

profit organizations

To build capacity to implement changes for

community prevention efforts to ensure long-

term success

To implement evidence-based and practice-

based programs to improve health amp wellness

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Priority areas are

Tobacco-free living

Active living and healthy eating

Evidence-based quality clinical and other

preventive health services for prevention

and control of high blood pressure and

high cholesterol

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Applicants proposed specific activities in

line with their chosen priority areas in their

applications

Grantee activities will not be finalized until

plans are negotiated with CDC by early

2012

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Capacity-Building Award

The Confederated Tribes of The Chehalis

Reservation is receiving a $498663 planning

award to build capacity to support healthy

lifestyles among their tribal population of 1500

in Washington State

Work will target tobacco-free living active living

and healthy eating and quality clinical and other

healthy serviceswwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Implementation Award

Austin TX Dept of Health and Human Services

is receiving $1026158 to serve Travis County

(Austin) to expand efforts in tobacco-free living

active living and healthy eating quality clinical

and other preventive services social and

emotional wellness and healthy and safe

physical environmentswwwcdcgov1052011

Building sustainable healthy

communities Bottom line

Obesity is an environmental problem

Despite progress in genetic research public health advances only will occur when we take the environment seriously

Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment

Until we do this we will not make substantial progress in addressing the epidemic of obesity

Poston amp Foreyt Atherosclerosis 1999

Whatrsquos the best approach

Integrate all sectors of society into community

change interventions

Incorporate

Science amp Technology

Education

FamilyCommunity

Healthcare

Arts amp Entertainment

Law amp Politics

Commerce amp Trade

Sectors of Society

Arts amp Entertainm

ent

Commerce amp Trade

Education

FamilyCommunity

Healthcare

Law amp Politics

Science amp Technology

Project FIT rationale design and baseline characteristics of a school- and community-

based intervention to address physical activity and healthy eating among low-income

elementary school children

Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D

Oh HJ Orth J Randall S Mayfield K Holmes D

Source

Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu

Abstract

BACKGROUND

This paper describes Project FIT a collaboration between the public school system local

health systems physicians neighborhood associations businesses faith-based leaders

community agencies and university researchers to develop a multi-faceted approach to

promote physical activity and healthy eating toward the general goal of preventing and

reducing childhood obesity among children in Grand Rapids MI USA

METHODSDESIGN

There are four overall components to Project FIT school community social marketing and

school staff wellness - all that focus on 1) increasing access to safe and affordable physical

activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)

improving the affordability and availability of nutritious food in the neighborhoods surrounding

the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding

nutrition and physical activity among school staff parents and students 4) impacting the

culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging

dialogue among all community partners to leverage existing programs and introduce new

ones

Percent Substandard (or worse) Housing

or Ground Conditions

of Residential Properties

0

10

20

30

Structural Grounds

Perc

en

t (

)

Low-Income High-Income

CONCLUSIONS

These data suggest that the higher

frequency of outlets providing

calorically-dense foods and alcohol may

contribute to greater obesity prevalence

in residents of low-income communities

More research is needed to thoroughly

document environmental determinants

of health and obesity

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

From 1994-1998 HUD randomly assigned

4498 women with children living in public

housing in high-poverty urban census

tracts to one of three groups (1) housing

vouchers redeemable only if they moved

to a low-poverty census tract (2)

unrestricted vouchers or (3) control group

(no vouchers)

Ludwig et al NEJM 201136516

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

10-12 year follow-up showed modest but

potentially important reductions in the

prevalence of extreme obesity amp diabetes in the

group moving from a neighborhood with high

poverty on one of low poverty compared to the

control group

No differences between the group receiving

traditional vouchers amp the control group

ldquoNeighborhoods matterrdquo

Ludwig et al NEJM 201136516

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance traffic safety in areas where

persons are or could be physically active

--Community-scale urban design amp land use policies to

promote physical activity including design components

to improve street lighting infrastructure projects to

increase safety of pedestrian street crossing and use of

traffic calming approaches such as speed humps amp

traffic circles are effective in increasing physical activity

--Both community-scale amp street-scale policies amp practices

are effective in increasing physical activity

Recommended Community Strategies Encourage Communities to Organize for Change

Participate in community coalitions or

partnerships to address obesity

--Little evidence is available to determine the

impact of community coalitions on obesity

prevention

--The presence of anti-smoking community

coalitions has been associated with lower rates

of tobacco consumption

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

$103 million awarded to 61 states and

communities including state amp local government

agencies tribes amp territories amp state amp local non-

profit organizations

To build capacity to implement changes for

community prevention efforts to ensure long-

term success

To implement evidence-based and practice-

based programs to improve health amp wellness

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Priority areas are

Tobacco-free living

Active living and healthy eating

Evidence-based quality clinical and other

preventive health services for prevention

and control of high blood pressure and

high cholesterol

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Applicants proposed specific activities in

line with their chosen priority areas in their

applications

Grantee activities will not be finalized until

plans are negotiated with CDC by early

2012

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Capacity-Building Award

The Confederated Tribes of The Chehalis

Reservation is receiving a $498663 planning

award to build capacity to support healthy

lifestyles among their tribal population of 1500

in Washington State

Work will target tobacco-free living active living

and healthy eating and quality clinical and other

healthy serviceswwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Implementation Award

Austin TX Dept of Health and Human Services

is receiving $1026158 to serve Travis County

(Austin) to expand efforts in tobacco-free living

active living and healthy eating quality clinical

and other preventive services social and

emotional wellness and healthy and safe

physical environmentswwwcdcgov1052011

Building sustainable healthy

communities Bottom line

Obesity is an environmental problem

Despite progress in genetic research public health advances only will occur when we take the environment seriously

Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment

Until we do this we will not make substantial progress in addressing the epidemic of obesity

Poston amp Foreyt Atherosclerosis 1999

Whatrsquos the best approach

Integrate all sectors of society into community

change interventions

Incorporate

Science amp Technology

Education

FamilyCommunity

Healthcare

Arts amp Entertainment

Law amp Politics

Commerce amp Trade

Sectors of Society

Arts amp Entertainm

ent

Commerce amp Trade

Education

FamilyCommunity

Healthcare

Law amp Politics

Science amp Technology

Project FIT rationale design and baseline characteristics of a school- and community-

based intervention to address physical activity and healthy eating among low-income

elementary school children

Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D

Oh HJ Orth J Randall S Mayfield K Holmes D

Source

Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu

Abstract

BACKGROUND

This paper describes Project FIT a collaboration between the public school system local

health systems physicians neighborhood associations businesses faith-based leaders

community agencies and university researchers to develop a multi-faceted approach to

promote physical activity and healthy eating toward the general goal of preventing and

reducing childhood obesity among children in Grand Rapids MI USA

METHODSDESIGN

There are four overall components to Project FIT school community social marketing and

school staff wellness - all that focus on 1) increasing access to safe and affordable physical

activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)

improving the affordability and availability of nutritious food in the neighborhoods surrounding

the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding

nutrition and physical activity among school staff parents and students 4) impacting the

culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging

dialogue among all community partners to leverage existing programs and introduce new

ones

CONCLUSIONS

These data suggest that the higher

frequency of outlets providing

calorically-dense foods and alcohol may

contribute to greater obesity prevalence

in residents of low-income communities

More research is needed to thoroughly

document environmental determinants

of health and obesity

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

From 1994-1998 HUD randomly assigned

4498 women with children living in public

housing in high-poverty urban census

tracts to one of three groups (1) housing

vouchers redeemable only if they moved

to a low-poverty census tract (2)

unrestricted vouchers or (3) control group

(no vouchers)

Ludwig et al NEJM 201136516

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

10-12 year follow-up showed modest but

potentially important reductions in the

prevalence of extreme obesity amp diabetes in the

group moving from a neighborhood with high

poverty on one of low poverty compared to the

control group

No differences between the group receiving

traditional vouchers amp the control group

ldquoNeighborhoods matterrdquo

Ludwig et al NEJM 201136516

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance traffic safety in areas where

persons are or could be physically active

--Community-scale urban design amp land use policies to

promote physical activity including design components

to improve street lighting infrastructure projects to

increase safety of pedestrian street crossing and use of

traffic calming approaches such as speed humps amp

traffic circles are effective in increasing physical activity

--Both community-scale amp street-scale policies amp practices

are effective in increasing physical activity

Recommended Community Strategies Encourage Communities to Organize for Change

Participate in community coalitions or

partnerships to address obesity

--Little evidence is available to determine the

impact of community coalitions on obesity

prevention

--The presence of anti-smoking community

coalitions has been associated with lower rates

of tobacco consumption

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

$103 million awarded to 61 states and

communities including state amp local government

agencies tribes amp territories amp state amp local non-

profit organizations

To build capacity to implement changes for

community prevention efforts to ensure long-

term success

To implement evidence-based and practice-

based programs to improve health amp wellness

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Priority areas are

Tobacco-free living

Active living and healthy eating

Evidence-based quality clinical and other

preventive health services for prevention

and control of high blood pressure and

high cholesterol

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Applicants proposed specific activities in

line with their chosen priority areas in their

applications

Grantee activities will not be finalized until

plans are negotiated with CDC by early

2012

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Capacity-Building Award

The Confederated Tribes of The Chehalis

Reservation is receiving a $498663 planning

award to build capacity to support healthy

lifestyles among their tribal population of 1500

in Washington State

Work will target tobacco-free living active living

and healthy eating and quality clinical and other

healthy serviceswwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Implementation Award

Austin TX Dept of Health and Human Services

is receiving $1026158 to serve Travis County

(Austin) to expand efforts in tobacco-free living

active living and healthy eating quality clinical

and other preventive services social and

emotional wellness and healthy and safe

physical environmentswwwcdcgov1052011

Building sustainable healthy

communities Bottom line

Obesity is an environmental problem

Despite progress in genetic research public health advances only will occur when we take the environment seriously

Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment

Until we do this we will not make substantial progress in addressing the epidemic of obesity

Poston amp Foreyt Atherosclerosis 1999

Whatrsquos the best approach

Integrate all sectors of society into community

change interventions

Incorporate

Science amp Technology

Education

FamilyCommunity

Healthcare

Arts amp Entertainment

Law amp Politics

Commerce amp Trade

Sectors of Society

Arts amp Entertainm

ent

Commerce amp Trade

Education

FamilyCommunity

Healthcare

Law amp Politics

Science amp Technology

Project FIT rationale design and baseline characteristics of a school- and community-

based intervention to address physical activity and healthy eating among low-income

elementary school children

Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D

Oh HJ Orth J Randall S Mayfield K Holmes D

Source

Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu

Abstract

BACKGROUND

This paper describes Project FIT a collaboration between the public school system local

health systems physicians neighborhood associations businesses faith-based leaders

community agencies and university researchers to develop a multi-faceted approach to

promote physical activity and healthy eating toward the general goal of preventing and

reducing childhood obesity among children in Grand Rapids MI USA

METHODSDESIGN

There are four overall components to Project FIT school community social marketing and

school staff wellness - all that focus on 1) increasing access to safe and affordable physical

activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)

improving the affordability and availability of nutritious food in the neighborhoods surrounding

the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding

nutrition and physical activity among school staff parents and students 4) impacting the

culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging

dialogue among all community partners to leverage existing programs and introduce new

ones

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

From 1994-1998 HUD randomly assigned

4498 women with children living in public

housing in high-poverty urban census

tracts to one of three groups (1) housing

vouchers redeemable only if they moved

to a low-poverty census tract (2)

unrestricted vouchers or (3) control group

(no vouchers)

Ludwig et al NEJM 201136516

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

10-12 year follow-up showed modest but

potentially important reductions in the

prevalence of extreme obesity amp diabetes in the

group moving from a neighborhood with high

poverty on one of low poverty compared to the

control group

No differences between the group receiving

traditional vouchers amp the control group

ldquoNeighborhoods matterrdquo

Ludwig et al NEJM 201136516

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance traffic safety in areas where

persons are or could be physically active

--Community-scale urban design amp land use policies to

promote physical activity including design components

to improve street lighting infrastructure projects to

increase safety of pedestrian street crossing and use of

traffic calming approaches such as speed humps amp

traffic circles are effective in increasing physical activity

--Both community-scale amp street-scale policies amp practices

are effective in increasing physical activity

Recommended Community Strategies Encourage Communities to Organize for Change

Participate in community coalitions or

partnerships to address obesity

--Little evidence is available to determine the

impact of community coalitions on obesity

prevention

--The presence of anti-smoking community

coalitions has been associated with lower rates

of tobacco consumption

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

$103 million awarded to 61 states and

communities including state amp local government

agencies tribes amp territories amp state amp local non-

profit organizations

To build capacity to implement changes for

community prevention efforts to ensure long-

term success

To implement evidence-based and practice-

based programs to improve health amp wellness

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Priority areas are

Tobacco-free living

Active living and healthy eating

Evidence-based quality clinical and other

preventive health services for prevention

and control of high blood pressure and

high cholesterol

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Applicants proposed specific activities in

line with their chosen priority areas in their

applications

Grantee activities will not be finalized until

plans are negotiated with CDC by early

2012

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Capacity-Building Award

The Confederated Tribes of The Chehalis

Reservation is receiving a $498663 planning

award to build capacity to support healthy

lifestyles among their tribal population of 1500

in Washington State

Work will target tobacco-free living active living

and healthy eating and quality clinical and other

healthy serviceswwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Implementation Award

Austin TX Dept of Health and Human Services

is receiving $1026158 to serve Travis County

(Austin) to expand efforts in tobacco-free living

active living and healthy eating quality clinical

and other preventive services social and

emotional wellness and healthy and safe

physical environmentswwwcdcgov1052011

Building sustainable healthy

communities Bottom line

Obesity is an environmental problem

Despite progress in genetic research public health advances only will occur when we take the environment seriously

Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment

Until we do this we will not make substantial progress in addressing the epidemic of obesity

Poston amp Foreyt Atherosclerosis 1999

Whatrsquos the best approach

Integrate all sectors of society into community

change interventions

Incorporate

Science amp Technology

Education

FamilyCommunity

Healthcare

Arts amp Entertainment

Law amp Politics

Commerce amp Trade

Sectors of Society

Arts amp Entertainm

ent

Commerce amp Trade

Education

FamilyCommunity

Healthcare

Law amp Politics

Science amp Technology

Project FIT rationale design and baseline characteristics of a school- and community-

based intervention to address physical activity and healthy eating among low-income

elementary school children

Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D

Oh HJ Orth J Randall S Mayfield K Holmes D

Source

Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu

Abstract

BACKGROUND

This paper describes Project FIT a collaboration between the public school system local

health systems physicians neighborhood associations businesses faith-based leaders

community agencies and university researchers to develop a multi-faceted approach to

promote physical activity and healthy eating toward the general goal of preventing and

reducing childhood obesity among children in Grand Rapids MI USA

METHODSDESIGN

There are four overall components to Project FIT school community social marketing and

school staff wellness - all that focus on 1) increasing access to safe and affordable physical

activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)

improving the affordability and availability of nutritious food in the neighborhoods surrounding

the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding

nutrition and physical activity among school staff parents and students 4) impacting the

culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging

dialogue among all community partners to leverage existing programs and introduce new

ones

Neighborhoods Obesity and Diabetes

A Randomized Social Experiment

10-12 year follow-up showed modest but

potentially important reductions in the

prevalence of extreme obesity amp diabetes in the

group moving from a neighborhood with high

poverty on one of low poverty compared to the

control group

No differences between the group receiving

traditional vouchers amp the control group

ldquoNeighborhoods matterrdquo

Ludwig et al NEJM 201136516

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance traffic safety in areas where

persons are or could be physically active

--Community-scale urban design amp land use policies to

promote physical activity including design components

to improve street lighting infrastructure projects to

increase safety of pedestrian street crossing and use of

traffic calming approaches such as speed humps amp

traffic circles are effective in increasing physical activity

--Both community-scale amp street-scale policies amp practices

are effective in increasing physical activity

Recommended Community Strategies Encourage Communities to Organize for Change

Participate in community coalitions or

partnerships to address obesity

--Little evidence is available to determine the

impact of community coalitions on obesity

prevention

--The presence of anti-smoking community

coalitions has been associated with lower rates

of tobacco consumption

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

$103 million awarded to 61 states and

communities including state amp local government

agencies tribes amp territories amp state amp local non-

profit organizations

To build capacity to implement changes for

community prevention efforts to ensure long-

term success

To implement evidence-based and practice-

based programs to improve health amp wellness

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Priority areas are

Tobacco-free living

Active living and healthy eating

Evidence-based quality clinical and other

preventive health services for prevention

and control of high blood pressure and

high cholesterol

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Applicants proposed specific activities in

line with their chosen priority areas in their

applications

Grantee activities will not be finalized until

plans are negotiated with CDC by early

2012

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Capacity-Building Award

The Confederated Tribes of The Chehalis

Reservation is receiving a $498663 planning

award to build capacity to support healthy

lifestyles among their tribal population of 1500

in Washington State

Work will target tobacco-free living active living

and healthy eating and quality clinical and other

healthy serviceswwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Implementation Award

Austin TX Dept of Health and Human Services

is receiving $1026158 to serve Travis County

(Austin) to expand efforts in tobacco-free living

active living and healthy eating quality clinical

and other preventive services social and

emotional wellness and healthy and safe

physical environmentswwwcdcgov1052011

Building sustainable healthy

communities Bottom line

Obesity is an environmental problem

Despite progress in genetic research public health advances only will occur when we take the environment seriously

Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment

Until we do this we will not make substantial progress in addressing the epidemic of obesity

Poston amp Foreyt Atherosclerosis 1999

Whatrsquos the best approach

Integrate all sectors of society into community

change interventions

Incorporate

Science amp Technology

Education

FamilyCommunity

Healthcare

Arts amp Entertainment

Law amp Politics

Commerce amp Trade

Sectors of Society

Arts amp Entertainm

ent

Commerce amp Trade

Education

FamilyCommunity

Healthcare

Law amp Politics

Science amp Technology

Project FIT rationale design and baseline characteristics of a school- and community-

based intervention to address physical activity and healthy eating among low-income

elementary school children

Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D

Oh HJ Orth J Randall S Mayfield K Holmes D

Source

Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu

Abstract

BACKGROUND

This paper describes Project FIT a collaboration between the public school system local

health systems physicians neighborhood associations businesses faith-based leaders

community agencies and university researchers to develop a multi-faceted approach to

promote physical activity and healthy eating toward the general goal of preventing and

reducing childhood obesity among children in Grand Rapids MI USA

METHODSDESIGN

There are four overall components to Project FIT school community social marketing and

school staff wellness - all that focus on 1) increasing access to safe and affordable physical

activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)

improving the affordability and availability of nutritious food in the neighborhoods surrounding

the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding

nutrition and physical activity among school staff parents and students 4) impacting the

culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging

dialogue among all community partners to leverage existing programs and introduce new

ones

Recommended Community Strategies Strategies to create safe communities that support physical

activity

Enhance traffic safety in areas where

persons are or could be physically active

--Community-scale urban design amp land use policies to

promote physical activity including design components

to improve street lighting infrastructure projects to

increase safety of pedestrian street crossing and use of

traffic calming approaches such as speed humps amp

traffic circles are effective in increasing physical activity

--Both community-scale amp street-scale policies amp practices

are effective in increasing physical activity

Recommended Community Strategies Encourage Communities to Organize for Change

Participate in community coalitions or

partnerships to address obesity

--Little evidence is available to determine the

impact of community coalitions on obesity

prevention

--The presence of anti-smoking community

coalitions has been associated with lower rates

of tobacco consumption

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

$103 million awarded to 61 states and

communities including state amp local government

agencies tribes amp territories amp state amp local non-

profit organizations

To build capacity to implement changes for

community prevention efforts to ensure long-

term success

To implement evidence-based and practice-

based programs to improve health amp wellness

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Priority areas are

Tobacco-free living

Active living and healthy eating

Evidence-based quality clinical and other

preventive health services for prevention

and control of high blood pressure and

high cholesterol

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Applicants proposed specific activities in

line with their chosen priority areas in their

applications

Grantee activities will not be finalized until

plans are negotiated with CDC by early

2012

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Capacity-Building Award

The Confederated Tribes of The Chehalis

Reservation is receiving a $498663 planning

award to build capacity to support healthy

lifestyles among their tribal population of 1500

in Washington State

Work will target tobacco-free living active living

and healthy eating and quality clinical and other

healthy serviceswwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Implementation Award

Austin TX Dept of Health and Human Services

is receiving $1026158 to serve Travis County

(Austin) to expand efforts in tobacco-free living

active living and healthy eating quality clinical

and other preventive services social and

emotional wellness and healthy and safe

physical environmentswwwcdcgov1052011

Building sustainable healthy

communities Bottom line

Obesity is an environmental problem

Despite progress in genetic research public health advances only will occur when we take the environment seriously

Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment

Until we do this we will not make substantial progress in addressing the epidemic of obesity

Poston amp Foreyt Atherosclerosis 1999

Whatrsquos the best approach

Integrate all sectors of society into community

change interventions

Incorporate

Science amp Technology

Education

FamilyCommunity

Healthcare

Arts amp Entertainment

Law amp Politics

Commerce amp Trade

Sectors of Society

Arts amp Entertainm

ent

Commerce amp Trade

Education

FamilyCommunity

Healthcare

Law amp Politics

Science amp Technology

Project FIT rationale design and baseline characteristics of a school- and community-

based intervention to address physical activity and healthy eating among low-income

elementary school children

Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D

Oh HJ Orth J Randall S Mayfield K Holmes D

Source

Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu

Abstract

BACKGROUND

This paper describes Project FIT a collaboration between the public school system local

health systems physicians neighborhood associations businesses faith-based leaders

community agencies and university researchers to develop a multi-faceted approach to

promote physical activity and healthy eating toward the general goal of preventing and

reducing childhood obesity among children in Grand Rapids MI USA

METHODSDESIGN

There are four overall components to Project FIT school community social marketing and

school staff wellness - all that focus on 1) increasing access to safe and affordable physical

activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)

improving the affordability and availability of nutritious food in the neighborhoods surrounding

the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding

nutrition and physical activity among school staff parents and students 4) impacting the

culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging

dialogue among all community partners to leverage existing programs and introduce new

ones

Recommended Community Strategies Encourage Communities to Organize for Change

Participate in community coalitions or

partnerships to address obesity

--Little evidence is available to determine the

impact of community coalitions on obesity

prevention

--The presence of anti-smoking community

coalitions has been associated with lower rates

of tobacco consumption

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

$103 million awarded to 61 states and

communities including state amp local government

agencies tribes amp territories amp state amp local non-

profit organizations

To build capacity to implement changes for

community prevention efforts to ensure long-

term success

To implement evidence-based and practice-

based programs to improve health amp wellness

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Priority areas are

Tobacco-free living

Active living and healthy eating

Evidence-based quality clinical and other

preventive health services for prevention

and control of high blood pressure and

high cholesterol

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Applicants proposed specific activities in

line with their chosen priority areas in their

applications

Grantee activities will not be finalized until

plans are negotiated with CDC by early

2012

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Capacity-Building Award

The Confederated Tribes of The Chehalis

Reservation is receiving a $498663 planning

award to build capacity to support healthy

lifestyles among their tribal population of 1500

in Washington State

Work will target tobacco-free living active living

and healthy eating and quality clinical and other

healthy serviceswwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Implementation Award

Austin TX Dept of Health and Human Services

is receiving $1026158 to serve Travis County

(Austin) to expand efforts in tobacco-free living

active living and healthy eating quality clinical

and other preventive services social and

emotional wellness and healthy and safe

physical environmentswwwcdcgov1052011

Building sustainable healthy

communities Bottom line

Obesity is an environmental problem

Despite progress in genetic research public health advances only will occur when we take the environment seriously

Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment

Until we do this we will not make substantial progress in addressing the epidemic of obesity

Poston amp Foreyt Atherosclerosis 1999

Whatrsquos the best approach

Integrate all sectors of society into community

change interventions

Incorporate

Science amp Technology

Education

FamilyCommunity

Healthcare

Arts amp Entertainment

Law amp Politics

Commerce amp Trade

Sectors of Society

Arts amp Entertainm

ent

Commerce amp Trade

Education

FamilyCommunity

Healthcare

Law amp Politics

Science amp Technology

Project FIT rationale design and baseline characteristics of a school- and community-

based intervention to address physical activity and healthy eating among low-income

elementary school children

Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D

Oh HJ Orth J Randall S Mayfield K Holmes D

Source

Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu

Abstract

BACKGROUND

This paper describes Project FIT a collaboration between the public school system local

health systems physicians neighborhood associations businesses faith-based leaders

community agencies and university researchers to develop a multi-faceted approach to

promote physical activity and healthy eating toward the general goal of preventing and

reducing childhood obesity among children in Grand Rapids MI USA

METHODSDESIGN

There are four overall components to Project FIT school community social marketing and

school staff wellness - all that focus on 1) increasing access to safe and affordable physical

activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)

improving the affordability and availability of nutritious food in the neighborhoods surrounding

the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding

nutrition and physical activity among school staff parents and students 4) impacting the

culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging

dialogue among all community partners to leverage existing programs and introduce new

ones

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

$103 million awarded to 61 states and

communities including state amp local government

agencies tribes amp territories amp state amp local non-

profit organizations

To build capacity to implement changes for

community prevention efforts to ensure long-

term success

To implement evidence-based and practice-

based programs to improve health amp wellness

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Priority areas are

Tobacco-free living

Active living and healthy eating

Evidence-based quality clinical and other

preventive health services for prevention

and control of high blood pressure and

high cholesterol

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Applicants proposed specific activities in

line with their chosen priority areas in their

applications

Grantee activities will not be finalized until

plans are negotiated with CDC by early

2012

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Capacity-Building Award

The Confederated Tribes of The Chehalis

Reservation is receiving a $498663 planning

award to build capacity to support healthy

lifestyles among their tribal population of 1500

in Washington State

Work will target tobacco-free living active living

and healthy eating and quality clinical and other

healthy serviceswwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Implementation Award

Austin TX Dept of Health and Human Services

is receiving $1026158 to serve Travis County

(Austin) to expand efforts in tobacco-free living

active living and healthy eating quality clinical

and other preventive services social and

emotional wellness and healthy and safe

physical environmentswwwcdcgov1052011

Building sustainable healthy

communities Bottom line

Obesity is an environmental problem

Despite progress in genetic research public health advances only will occur when we take the environment seriously

Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment

Until we do this we will not make substantial progress in addressing the epidemic of obesity

Poston amp Foreyt Atherosclerosis 1999

Whatrsquos the best approach

Integrate all sectors of society into community

change interventions

Incorporate

Science amp Technology

Education

FamilyCommunity

Healthcare

Arts amp Entertainment

Law amp Politics

Commerce amp Trade

Sectors of Society

Arts amp Entertainm

ent

Commerce amp Trade

Education

FamilyCommunity

Healthcare

Law amp Politics

Science amp Technology

Project FIT rationale design and baseline characteristics of a school- and community-

based intervention to address physical activity and healthy eating among low-income

elementary school children

Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D

Oh HJ Orth J Randall S Mayfield K Holmes D

Source

Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu

Abstract

BACKGROUND

This paper describes Project FIT a collaboration between the public school system local

health systems physicians neighborhood associations businesses faith-based leaders

community agencies and university researchers to develop a multi-faceted approach to

promote physical activity and healthy eating toward the general goal of preventing and

reducing childhood obesity among children in Grand Rapids MI USA

METHODSDESIGN

There are four overall components to Project FIT school community social marketing and

school staff wellness - all that focus on 1) increasing access to safe and affordable physical

activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)

improving the affordability and availability of nutritious food in the neighborhoods surrounding

the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding

nutrition and physical activity among school staff parents and students 4) impacting the

culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging

dialogue among all community partners to leverage existing programs and introduce new

ones

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Priority areas are

Tobacco-free living

Active living and healthy eating

Evidence-based quality clinical and other

preventive health services for prevention

and control of high blood pressure and

high cholesterol

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Applicants proposed specific activities in

line with their chosen priority areas in their

applications

Grantee activities will not be finalized until

plans are negotiated with CDC by early

2012

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Capacity-Building Award

The Confederated Tribes of The Chehalis

Reservation is receiving a $498663 planning

award to build capacity to support healthy

lifestyles among their tribal population of 1500

in Washington State

Work will target tobacco-free living active living

and healthy eating and quality clinical and other

healthy serviceswwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Implementation Award

Austin TX Dept of Health and Human Services

is receiving $1026158 to serve Travis County

(Austin) to expand efforts in tobacco-free living

active living and healthy eating quality clinical

and other preventive services social and

emotional wellness and healthy and safe

physical environmentswwwcdcgov1052011

Building sustainable healthy

communities Bottom line

Obesity is an environmental problem

Despite progress in genetic research public health advances only will occur when we take the environment seriously

Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment

Until we do this we will not make substantial progress in addressing the epidemic of obesity

Poston amp Foreyt Atherosclerosis 1999

Whatrsquos the best approach

Integrate all sectors of society into community

change interventions

Incorporate

Science amp Technology

Education

FamilyCommunity

Healthcare

Arts amp Entertainment

Law amp Politics

Commerce amp Trade

Sectors of Society

Arts amp Entertainm

ent

Commerce amp Trade

Education

FamilyCommunity

Healthcare

Law amp Politics

Science amp Technology

Project FIT rationale design and baseline characteristics of a school- and community-

based intervention to address physical activity and healthy eating among low-income

elementary school children

Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D

Oh HJ Orth J Randall S Mayfield K Holmes D

Source

Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu

Abstract

BACKGROUND

This paper describes Project FIT a collaboration between the public school system local

health systems physicians neighborhood associations businesses faith-based leaders

community agencies and university researchers to develop a multi-faceted approach to

promote physical activity and healthy eating toward the general goal of preventing and

reducing childhood obesity among children in Grand Rapids MI USA

METHODSDESIGN

There are four overall components to Project FIT school community social marketing and

school staff wellness - all that focus on 1) increasing access to safe and affordable physical

activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)

improving the affordability and availability of nutritious food in the neighborhoods surrounding

the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding

nutrition and physical activity among school staff parents and students 4) impacting the

culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging

dialogue among all community partners to leverage existing programs and introduce new

ones

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Applicants proposed specific activities in

line with their chosen priority areas in their

applications

Grantee activities will not be finalized until

plans are negotiated with CDC by early

2012

wwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Capacity-Building Award

The Confederated Tribes of The Chehalis

Reservation is receiving a $498663 planning

award to build capacity to support healthy

lifestyles among their tribal population of 1500

in Washington State

Work will target tobacco-free living active living

and healthy eating and quality clinical and other

healthy serviceswwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Implementation Award

Austin TX Dept of Health and Human Services

is receiving $1026158 to serve Travis County

(Austin) to expand efforts in tobacco-free living

active living and healthy eating quality clinical

and other preventive services social and

emotional wellness and healthy and safe

physical environmentswwwcdcgov1052011

Building sustainable healthy

communities Bottom line

Obesity is an environmental problem

Despite progress in genetic research public health advances only will occur when we take the environment seriously

Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment

Until we do this we will not make substantial progress in addressing the epidemic of obesity

Poston amp Foreyt Atherosclerosis 1999

Whatrsquos the best approach

Integrate all sectors of society into community

change interventions

Incorporate

Science amp Technology

Education

FamilyCommunity

Healthcare

Arts amp Entertainment

Law amp Politics

Commerce amp Trade

Sectors of Society

Arts amp Entertainm

ent

Commerce amp Trade

Education

FamilyCommunity

Healthcare

Law amp Politics

Science amp Technology

Project FIT rationale design and baseline characteristics of a school- and community-

based intervention to address physical activity and healthy eating among low-income

elementary school children

Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D

Oh HJ Orth J Randall S Mayfield K Holmes D

Source

Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu

Abstract

BACKGROUND

This paper describes Project FIT a collaboration between the public school system local

health systems physicians neighborhood associations businesses faith-based leaders

community agencies and university researchers to develop a multi-faceted approach to

promote physical activity and healthy eating toward the general goal of preventing and

reducing childhood obesity among children in Grand Rapids MI USA

METHODSDESIGN

There are four overall components to Project FIT school community social marketing and

school staff wellness - all that focus on 1) increasing access to safe and affordable physical

activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)

improving the affordability and availability of nutritious food in the neighborhoods surrounding

the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding

nutrition and physical activity among school staff parents and students 4) impacting the

culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging

dialogue among all community partners to leverage existing programs and introduce new

ones

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Capacity-Building Award

The Confederated Tribes of The Chehalis

Reservation is receiving a $498663 planning

award to build capacity to support healthy

lifestyles among their tribal population of 1500

in Washington State

Work will target tobacco-free living active living

and healthy eating and quality clinical and other

healthy serviceswwwcdcgov1052011

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Implementation Award

Austin TX Dept of Health and Human Services

is receiving $1026158 to serve Travis County

(Austin) to expand efforts in tobacco-free living

active living and healthy eating quality clinical

and other preventive services social and

emotional wellness and healthy and safe

physical environmentswwwcdcgov1052011

Building sustainable healthy

communities Bottom line

Obesity is an environmental problem

Despite progress in genetic research public health advances only will occur when we take the environment seriously

Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment

Until we do this we will not make substantial progress in addressing the epidemic of obesity

Poston amp Foreyt Atherosclerosis 1999

Whatrsquos the best approach

Integrate all sectors of society into community

change interventions

Incorporate

Science amp Technology

Education

FamilyCommunity

Healthcare

Arts amp Entertainment

Law amp Politics

Commerce amp Trade

Sectors of Society

Arts amp Entertainm

ent

Commerce amp Trade

Education

FamilyCommunity

Healthcare

Law amp Politics

Science amp Technology

Project FIT rationale design and baseline characteristics of a school- and community-

based intervention to address physical activity and healthy eating among low-income

elementary school children

Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D

Oh HJ Orth J Randall S Mayfield K Holmes D

Source

Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu

Abstract

BACKGROUND

This paper describes Project FIT a collaboration between the public school system local

health systems physicians neighborhood associations businesses faith-based leaders

community agencies and university researchers to develop a multi-faceted approach to

promote physical activity and healthy eating toward the general goal of preventing and

reducing childhood obesity among children in Grand Rapids MI USA

METHODSDESIGN

There are four overall components to Project FIT school community social marketing and

school staff wellness - all that focus on 1) increasing access to safe and affordable physical

activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)

improving the affordability and availability of nutritious food in the neighborhoods surrounding

the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding

nutrition and physical activity among school staff parents and students 4) impacting the

culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging

dialogue among all community partners to leverage existing programs and introduce new

ones

What is the US Government doing

Community Transformation Grants (CTG) to

States and Communities

Example of Implementation Award

Austin TX Dept of Health and Human Services

is receiving $1026158 to serve Travis County

(Austin) to expand efforts in tobacco-free living

active living and healthy eating quality clinical

and other preventive services social and

emotional wellness and healthy and safe

physical environmentswwwcdcgov1052011

Building sustainable healthy

communities Bottom line

Obesity is an environmental problem

Despite progress in genetic research public health advances only will occur when we take the environment seriously

Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment

Until we do this we will not make substantial progress in addressing the epidemic of obesity

Poston amp Foreyt Atherosclerosis 1999

Whatrsquos the best approach

Integrate all sectors of society into community

change interventions

Incorporate

Science amp Technology

Education

FamilyCommunity

Healthcare

Arts amp Entertainment

Law amp Politics

Commerce amp Trade

Sectors of Society

Arts amp Entertainm

ent

Commerce amp Trade

Education

FamilyCommunity

Healthcare

Law amp Politics

Science amp Technology

Project FIT rationale design and baseline characteristics of a school- and community-

based intervention to address physical activity and healthy eating among low-income

elementary school children

Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D

Oh HJ Orth J Randall S Mayfield K Holmes D

Source

Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu

Abstract

BACKGROUND

This paper describes Project FIT a collaboration between the public school system local

health systems physicians neighborhood associations businesses faith-based leaders

community agencies and university researchers to develop a multi-faceted approach to

promote physical activity and healthy eating toward the general goal of preventing and

reducing childhood obesity among children in Grand Rapids MI USA

METHODSDESIGN

There are four overall components to Project FIT school community social marketing and

school staff wellness - all that focus on 1) increasing access to safe and affordable physical

activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)

improving the affordability and availability of nutritious food in the neighborhoods surrounding

the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding

nutrition and physical activity among school staff parents and students 4) impacting the

culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging

dialogue among all community partners to leverage existing programs and introduce new

ones

Building sustainable healthy

communities Bottom line

Obesity is an environmental problem

Despite progress in genetic research public health advances only will occur when we take the environment seriously

Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment

Until we do this we will not make substantial progress in addressing the epidemic of obesity

Poston amp Foreyt Atherosclerosis 1999

Whatrsquos the best approach

Integrate all sectors of society into community

change interventions

Incorporate

Science amp Technology

Education

FamilyCommunity

Healthcare

Arts amp Entertainment

Law amp Politics

Commerce amp Trade

Sectors of Society

Arts amp Entertainm

ent

Commerce amp Trade

Education

FamilyCommunity

Healthcare

Law amp Politics

Science amp Technology

Project FIT rationale design and baseline characteristics of a school- and community-

based intervention to address physical activity and healthy eating among low-income

elementary school children

Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D

Oh HJ Orth J Randall S Mayfield K Holmes D

Source

Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu

Abstract

BACKGROUND

This paper describes Project FIT a collaboration between the public school system local

health systems physicians neighborhood associations businesses faith-based leaders

community agencies and university researchers to develop a multi-faceted approach to

promote physical activity and healthy eating toward the general goal of preventing and

reducing childhood obesity among children in Grand Rapids MI USA

METHODSDESIGN

There are four overall components to Project FIT school community social marketing and

school staff wellness - all that focus on 1) increasing access to safe and affordable physical

activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)

improving the affordability and availability of nutritious food in the neighborhoods surrounding

the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding

nutrition and physical activity among school staff parents and students 4) impacting the

culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging

dialogue among all community partners to leverage existing programs and introduce new

ones

Whatrsquos the best approach

Integrate all sectors of society into community

change interventions

Incorporate

Science amp Technology

Education

FamilyCommunity

Healthcare

Arts amp Entertainment

Law amp Politics

Commerce amp Trade

Sectors of Society

Arts amp Entertainm

ent

Commerce amp Trade

Education

FamilyCommunity

Healthcare

Law amp Politics

Science amp Technology

Project FIT rationale design and baseline characteristics of a school- and community-

based intervention to address physical activity and healthy eating among low-income

elementary school children

Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D

Oh HJ Orth J Randall S Mayfield K Holmes D

Source

Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu

Abstract

BACKGROUND

This paper describes Project FIT a collaboration between the public school system local

health systems physicians neighborhood associations businesses faith-based leaders

community agencies and university researchers to develop a multi-faceted approach to

promote physical activity and healthy eating toward the general goal of preventing and

reducing childhood obesity among children in Grand Rapids MI USA

METHODSDESIGN

There are four overall components to Project FIT school community social marketing and

school staff wellness - all that focus on 1) increasing access to safe and affordable physical

activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)

improving the affordability and availability of nutritious food in the neighborhoods surrounding

the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding

nutrition and physical activity among school staff parents and students 4) impacting the

culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging

dialogue among all community partners to leverage existing programs and introduce new

ones

Project FIT rationale design and baseline characteristics of a school- and community-

based intervention to address physical activity and healthy eating among low-income

elementary school children

Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D

Oh HJ Orth J Randall S Mayfield K Holmes D

Source

Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu

Abstract

BACKGROUND

This paper describes Project FIT a collaboration between the public school system local

health systems physicians neighborhood associations businesses faith-based leaders

community agencies and university researchers to develop a multi-faceted approach to

promote physical activity and healthy eating toward the general goal of preventing and

reducing childhood obesity among children in Grand Rapids MI USA

METHODSDESIGN

There are four overall components to Project FIT school community social marketing and

school staff wellness - all that focus on 1) increasing access to safe and affordable physical

activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)

improving the affordability and availability of nutritious food in the neighborhoods surrounding

the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding

nutrition and physical activity among school staff parents and students 4) impacting the

culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging

dialogue among all community partners to leverage existing programs and introduce new

ones

ldquoThe Current Epidemics of Chronic Diseases

are a Result of Discordance Between Our

Ancient Genes and Modern Lifestylerdquo

Eaton et al The Paleolithic Prescription 1988

Building sustainable healthy

communities

ldquoAccuse not nature

She has done her part

Do Thou but Thinerdquo

John Milton (1687) Paradise Lost

Building sustainable healthy

communities

SECRETS OF SUCCESSFUL WEIGHT LOSS

Every Day

Sleep 8 hours

Eat breakfast

Walk briskly 60 minutes

Write down what you eat

Weigh

Find support

Never give up

ldquoAccuse not nature

She has done her part

Do Thou but Thinerdquo

John Milton (1687) Paradise Lost

Building sustainable healthy

communities

SECRETS OF SUCCESSFUL WEIGHT LOSS

Every Day

Sleep 8 hours

Eat breakfast

Walk briskly 60 minutes

Write down what you eat

Weigh

Find support

Never give up

SECRETS OF SUCCESSFUL WEIGHT LOSS

Every Day

Sleep 8 hours

Eat breakfast

Walk briskly 60 minutes

Write down what you eat

Weigh

Find support

Never give up