Obesity Advocacy: From Practice to Policy Sandra Hassink, MD, FAAP Chairperson, Obesity Leadership...

Obesity Advocacy: Obesity Advocacy: From Practice to Policy From Practice to Policy

Sandra Hassink, MD, FAAPSandra Hassink, MD, FAAPChairperson, Obesity Leadership WorkgroupChairperson, Obesity Leadership Workgroup

Director, Nemours Childhood Obesity Initiative Director, Nemours Childhood Obesity Initiative

A I DuPont Hospital for Children A I DuPont Hospital for Children

Wilmington, DE Wilmington, DE

DisclosureDisclosure

Member AAP Board of DirectorsMember AAP Board of Directors U S Prevention Advisory PanelU S Prevention Advisory Panel

Discussion Discussion

A quick look at the childhood obesity A quick look at the childhood obesity epidemicepidemic

Using the socioecological model to Using the socioecological model to frame the issuesframe the issues

Policy Tool in Practice Policy Tool in Practice Creating and sustaining advocacy Creating and sustaining advocacy

TeamsTeams

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Childhood Obesity in the US

www.ncsl.org/.../programs/health/ObesityMap.jpgThe National Survey of Children's Health, Overweight and Physical Activity Among Children: A Portrait of States and the Nation 2005; HRSA,Health, United States, U.S. Department of Health and Human Services,Centers for Disease Control and Prevention, National Center for Health Statistics, 2007.

National Perspective

http://www.ncsl.org/default.aspx?tabid=13877

National Perspective

The 2007 national Youth Risk Behavior SurveyThe 2007 national Youth Risk Behavior Survey(High School Students)(High School Students) 13% Obese 13% Obese Unhealthy Dietary BehaviorsUnhealthy Dietary Behaviors

– 79%79% ate fruits and vegetables less than five times per day ate fruits and vegetables less than five times per day during the 7 days before the survey.during the 7 days before the survey.

– 34%34% drank a can, bottle, or glass of soda or pop (not drank a can, bottle, or glass of soda or pop (not including diet soda or diet pop) at least one time per day including diet soda or diet pop) at least one time per day during the 7 days before the survey. during the 7 days before the survey.

Dietary Patterns

Physical Activity PatternsPhysical Activity PatternsThe 2007 National Youth Risk Behavior SurveyThe 2007 National Youth Risk Behavior Survey(High School Students) (High School Students) 65%65% did not meet recommended levels of physical activity did not meet recommended levels of physical activity

– 46%46% did not attend physical education classes. did not attend physical education classes. – 70%70% did not attend physical education classes daily. did not attend physical education classes daily. – 35%35% watched television 3 or more hours per day on an watched television 3 or more hours per day on an

average school day. average school day. – 25%25% played video or computer games or used a computer played video or computer games or used a computer

for something that was not school work for 3 or more for something that was not school work for 3 or more hours per day on an average school day. hours per day on an average school day.

Health ConsequencesHealth ConsequencesIn childhood, obese children are more at risk for:In childhood, obese children are more at risk for: Type 2 diabetes;Type 2 diabetes; High blood pressure;High blood pressure; Liver disease;Liver disease; Dyslipidemia including high cholesterol, high Dyslipidemia including high cholesterol, high

triglycerides and low HDL cholesterol;triglycerides and low HDL cholesterol; Upper Airway Obstruction Sleep Apnea Syndrome; Upper Airway Obstruction Sleep Apnea Syndrome;

andand Hip and knee problems.Hip and knee problems.

Health ConsequencesHealth Consequences In addition to the devastating physical health In addition to the devastating physical health

consequences, overweight and obese children consequences, overweight and obese children suffer social and emotional health consequences suffer social and emotional health consequences as well.as well.

Obese children:Obese children:– have lower self-esteem;have lower self-esteem;– are more likely to be depressed;are more likely to be depressed;– suffer from bullying and teasing; andsuffer from bullying and teasing; and– have lower academic achievement.have lower academic achievement.

Cost of ObesityCost of Obesity An obese child’s healthcare costs are roughly three An obese child’s healthcare costs are roughly three

times more than the average child.times more than the average child.

Childhood obesity is estimated to cost Childhood obesity is estimated to cost $14 billion$14 billion annually in direct and indirect health expenses.annually in direct and indirect health expenses.– Children in Medicaid account for $3 billion of those expensesChildren in Medicaid account for $3 billion of those expenses

Annual obesity-related hospital costs for children and Annual obesity-related hospital costs for children and adolescents were $238 million in 2005, nearly doubling adolescents were $238 million in 2005, nearly doubling between 2003 and 2005.between 2003 and 2005.

WhereWhere

Environmental Determinants of HealthEnvironmental Determinants of Health Where a child lives and goes to school has a Where a child lives and goes to school has a

significant impact on his healthsignificant impact on his health Today’s food and physical activity environment make Today’s food and physical activity environment make

it hard to be healthy. For example:it hard to be healthy. For example:– Lack of physical activity in schools (i.e. no PE or recess)Lack of physical activity in schools (i.e. no PE or recess)– Car-focused world – active transport (i.e. walking or Car-focused world – active transport (i.e. walking or

biking) is not easybiking) is not easy– Lack of available and affordable fresh fruits and veggiesLack of available and affordable fresh fruits and veggies– Massive marketing of unhealthy food and beveragesMassive marketing of unhealthy food and beverages– Overabundance of energy dense nutrient poor foods Overabundance of energy dense nutrient poor foods

Communities at RiskCommunities at Risk Communities at risk are neighborhoods and regions Communities at risk are neighborhoods and regions

where children are more likely to be where children are more likely to be overexposed to overexposed to unhealthy factors and underexposed to healthy unhealthy factors and underexposed to healthy ones.ones.– In these communities, resources are minimal, In these communities, resources are minimal,

infrastructure is not conducive to physical activity, income infrastructure is not conducive to physical activity, income is generally low, and economic opportunities may be is generally low, and economic opportunities may be scarce. scarce.

The rates of obesity in communities at risk continue The rates of obesity in communities at risk continue to rise far above those where children have access to to rise far above those where children have access to healthy foods and places where they can engage in healthy foods and places where they can engage in physical activity.physical activity.

Making the Link: Making the Link: Practice and CommunityPractice and Community

Case StudyCase Study A 12 year-old girl A 12 year-old girl

– At her 12 year well check mother reports her At her 12 year well check mother reports her daughter’s increasing comments about her weight daughter’s increasing comments about her weight and being “fat”.and being “fat”.

– BMI = 23, 90BMI = 23, 90th th percentile for a 12 year-old girl percentile for a 12 year-old girl – Identified as overweightIdentified as overweight

Community/Social/Demographic

Parenting Styles

Child Characteristics

Child’s WeightStatus

gender age

Dietary Intake

DecisionMaking family

genetics

SedentaryBehavior

PhysicalActivity

Schedule

ChildFeedingPractices

Peer/Sibling

InteractionsFoods

AvailableIn House

NutritionalKnowledge

ParentDietaryIntake Parent

FoodPreferences

ParentWeight Status

ParentEncouragement

of Activity

ParentActivityPatterns

Parent Monitoring

of TV

Family TVViewingSchool

Schedule

SchoolLunch

Program

Ethnicity

Work Hours

SchoolEnvironment

Availabilityof Recreational

Activities

Accessibility ofConvenience Foods

& Restaurants

FamilyLeisureTime

CornerStore

SchoolPhysical

EducationPrograms

Crime RatesGeneral Safety

SocioeconomicStatus

Activities At Home

Skips breakfast Skips breakfast (no time) (no time) Eats pretzel and juice for lunch Eats pretzel and juice for lunch (not hungry for (not hungry for

a regular lunch)a regular lunch) After school – soda and snack food After school – soda and snack food (poor (poor

choices)choices) Dinner – Family eats out 3x/week Dinner – Family eats out 3x/week (too busy to (too busy to

cook)cook) Bedtime – Cereal Bedtime – Cereal (eating while watching TV(eating while watching TV))

12 Year-Old GirlDietary Patterns – Behavioral PerspectiveBehavioral Perspective


Parenting Styles



gender age

Dietary Intake


genetics

SedentaryBehavior

PhysicalActivity

Schedule


Peer/Sibling

InteractionsFoods

AvailableIn House



FoodPreferences

ParentWeight Status

ParentEncouragement

of Activity


Parent Monitoring

of TV


Schedule

SchoolLunch

Program

Ethnicity

Work Hours

SchoolEnvironment


Activities


& Restaurants

FamilyLeisureTime

CornerStore

SchoolPhysical

EducationPrograms


SocioeconomicStatus

Activities At Home

12 Year-Old Girl12 Year-Old GirlDietary Patterns – Dietary Patterns – Environmental PerspectiveEnvironmental Perspective

Skips breakfast (Skips breakfast (school start time/availability school start time/availability of school breakfast)of school breakfast)

Eats pretzel and juice for lunch Eats pretzel and juice for lunch (school lunch)(school lunch) After school – soda and snack food After school – soda and snack food (corner (corner

store)store) Dinner – Family eats out 3x/week Dinner – Family eats out 3x/week (fast food (fast food

availability)availability) Bedtime – Cereal Bedtime – Cereal (TV in bedroom)(TV in bedroom)


Parenting Styles



gender age

Dietary Intake


genetics

SedentaryBehavior

PhysicalActivity

Schedule


Peer/Sibling

InteractionsFoods

AvailableIn House



FoodPreferences

ParentWeight Status

ParentEncouragement

of Activity


Parent Monitoring

of TV


Schedule

SchoolLunch

Program

Ethnicity

Work Hours

SchoolEnvironment


Activities


& Restaurants

FamilyLeisureTime

CornerStore

SchoolPhysical

EducationPrograms


SocioeconomicStatus

Activities At Home

12 Year-Old Girl 12 Year-Old Girl Physical Activity Patterns - Behavioral PerspectivePhysical Activity Patterns - Behavioral Perspective

No outdoor time No outdoor time (doesn’t want to go outside)(doesn’t want to go outside) Computer, IM etc 3 hours/day Computer, IM etc 3 hours/day (nothing else to do)(nothing else to do) Homework 2 hours/day Homework 2 hours/day (prefers not to do homework (prefers not to do homework

at study period)at study period) Weekends “TV all the time” Weekends “TV all the time” (doesn’t know what to (doesn’t know what to

do if not watching TV)do if not watching TV) Extracurricular activity - Cheerleading 2x/weekExtracurricular activity - Cheerleading 2x/week


Parenting Styles



gender age

Dietary Intake


genetics

SedentaryBehavior

PhysicalActivity

Schedule


Peer/Sibling

InteractionsFoods

AvailableIn House



FoodPreferences

ParentWeight Status

ParentEncouragement

of Activity


Parent Monitoring

of TV


Schedule

SchoolLunch

Program

Ethnicity

Work Hours

SchoolEnvironment


Activities


& Restaurants

FamilyLeisureTime

CornerStore

SchoolPhysical

EducationPrograms


SocioeconomicStatus

Activities At Home

12 Year-Old Girl 12 Year-Old Girl Physical Activity Patterns - Environmental PerspectivePhysical Activity Patterns - Environmental Perspective

No gym this session No gym this session (school schedule)(school schedule) No recess No recess (school schedule) (school schedule) No outdoor time No outdoor time (neighborhood safety)(neighborhood safety) Computer, IM etc 3 hours/day Computer, IM etc 3 hours/day (family (family

entertainment environment) entertainment environment) Homework 2 hours/day Homework 2 hours/day (family scheduling)(family scheduling) Weekends “TV all the time” Weekends “TV all the time” (family activity)(family activity) Extracurricular activity Cheerleading 2x/weekExtracurricular activity Cheerleading 2x/week


Parenting Styles



gender age

Dietary Intake


genetics

SedentaryBehavior

PhysicalActivity

Schedule


Peer/Sibling

InteractionsFoods

AvailableIn House



FoodPreferences

ParentWeight Status

ParentEncouragement

of Activity


Parent Monitoring

of TV


Schedule

SchoolLunch

Program

Ethnicity

Work Hours

SchoolEnvironment


Activities


& Restaurants

FamilyLeisureTime

CornerStore

SchoolPhysical

EducationPrograms


SocioeconomicStatus

Activities At Home

Obesity in the Context of Obesity in the Context of This 12 Year-Old’s EnvironmentThis 12 Year-Old’s Environment

Interaction of environment and behavior is Interaction of environment and behavior is criticalcritical

Making healthy decisions only works when Making healthy decisions only works when there are safe and affordable healthy options there are safe and affordable healthy options readily available in the environmentreadily available in the environment

The next slide highlights all the factors that The next slide highlights all the factors that influence this 12 year-old’s food and physical influence this 12 year-old’s food and physical activity environmentsactivity environments


Parenting Styles



gender age

Dietary Intake


genetics

SedentaryBehavior

PhysicalActivity

Schedule


Peer/Sibling

InteractionsFoods

AvailableIn House



FoodPreferences

ParentWeight Status

ParentEncouragement

of Activity


Parent Monitoring

of TV


Schedule

SchoolLunch

Program

Ethnicity

Work Hours

SchoolEnvironment


Activities


& Restaurants

FamilyLeisureTime

CornerStore

SchoolPhysical

EducationPrograms


SocioeconomicStatus

Activities At Home

WhoWho

PEDIATRICIANS Take ActionPEDIATRICIANS Take Action

You can help your patients and improve your clinical You can help your patients and improve your clinical care by becoming an advocate and being part of a care by becoming an advocate and being part of a movement to create healthy environments that movement to create healthy environments that foster healthy active living for foster healthy active living for all children.all children.

Children need you to be their advocates because Children need you to be their advocates because environmental change does not occur without environmental change does not occur without advocacy and children don’t have a voice in their advocacy and children don’t have a voice in their childcare/school operations, community, and public childcare/school operations, community, and public policy. policy.

You can provide the You can provide the voicevoice and the expertise to and the expertise to make positive changes in the environment.make positive changes in the environment.

Where? Where?

Creating an EnvironmentCreating an Environmentfor Healthy Active Livingfor Healthy Active Living

In our homesIn our homes In our own offices/workplacesIn our own offices/workplaces In schoolsIn schools In childcare In childcare In the communityIn the community

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How?How?

Policy Opportunities: HOW To Take ActionPolicy Opportunities: HOW To Take Action A variety of policy strategies exist to support healthier A variety of policy strategies exist to support healthier

communitiescommunities Centers for Disease Control & Prevention, Institute of Centers for Disease Control & Prevention, Institute of

Medicine, Robert Wood Johnson Foundation and AAP have Medicine, Robert Wood Johnson Foundation and AAP have identified some specific strategies that fall into the following identified some specific strategies that fall into the following categories:categories:– Improving access to healthy foods and beveragesImproving access to healthy foods and beverages– Limit access to unhealthy foods and beveragesLimit access to unhealthy foods and beverages– Improve opportunities for safe and affordable physical activityImprove opportunities for safe and affordable physical activity– Increase active transportation through community designIncrease active transportation through community design– Improve school and childcare environmentsImprove school and childcare environments– Support breastfeedingSupport breastfeeding

Policy Opportunities Tool Policy Opportunities Tool To further distill the various policy strategies, the To further distill the various policy strategies, the

AAP created a tool that looks at the different AAP created a tool that looks at the different opportunities in terms of:opportunities in terms of:– existing clinical anticipatory guidance and messaging (5, 2, existing clinical anticipatory guidance and messaging (5, 2,

1, 0,breastfeeding and BMI), and 1, 0,breastfeeding and BMI), and – the various sectors where changes can occur (practice, the various sectors where changes can occur (practice,

community, school, state, and federal)community, school, state, and federal) The tool also highlights which strategies are The tool also highlights which strategies are

recommended by AAP, CDC, IOM, RWJF, and/or the recommended by AAP, CDC, IOM, RWJF, and/or the National Governors AssociationNational Governors Association

www.aap.org/obesity/policymatrix

http://www.aap.org/obesity/matrix_1.html

Approach to AdvocacyApproach to Advocacy Traditional advocacy in a group settingTraditional advocacy in a group setting: one : one

person is the driver and does most of the person is the driver and does most of the work, others start out enthusiastic but fade work, others start out enthusiastic but fade away, initial leader gets overwhelmed and away, initial leader gets overwhelmed and overworked, initiative eventually falls apart.overworked, initiative eventually falls apart.

Team approachTeam approach: group develops goals and : group develops goals and assigns/volunteers for tasks together, tracking assigns/volunteers for tasks together, tracking and regular communication takes place, group and regular communication takes place, group reconvenes periodically to assess progress reconvenes periodically to assess progress and adjust course.and adjust course.

Creating, Strengthening and Creating, Strengthening and Supporting Advocacy TeamsSupporting Advocacy Teams

A real team – appropriately A real team – appropriately focused and rigorously focused and rigorously

disciplined - is the most flexible disciplined - is the most flexible and the most powerful unit of and the most powerful unit of performance, learning, and performance, learning, and change in today's complex change in today's complex

world.world.Katzenbach and Smith

Definition of a Real TeamDefinition of a Real Team

A real team is a small number of A real team is a small number of people withpeople with

complementary skills that are complementary skills that are committed to a common purpose, committed to a common purpose,

performance goals, and approach for performance goals, and approach for which they hold themselves mutually which they hold themselves mutually

accountable.accountable.Katzenbach and Smith

Team BasicsTeam Basics

Ski

llsProblem

solving

Technical/function

InterpersonalA

ccountabilityMutual

Small number of people

Individual

Collective WorkProducts

Personal Growth

PerformanceResults

Commitment

Specific goals

Common approach

Meaningful purpose

Leaders Enhance Team Leaders Enhance Team PerformancePerformance

Clarify purpose and goalsClarify purpose and goals Build commitment and self-confidenceBuild commitment and self-confidence Strengthen the team's collective skills Strengthen the team's collective skills

and approachand approach Remove externally imposed Remove externally imposed

obstaclesobstacles Create opportunities for othersCreate opportunities for others Do real workDo real work

Working Group vs. TeamWorking Group vs. Team

CollectiveWork

Products

Single-leader

working groupP

ositi

on s

kill

Individual accountability

Leader Leader driven

EfficiencyLeader's goalsand approach

Per

form

ance

res

ult

s

Time required

Real Team

Performance Driven

Team’s goals and approach

CollectiveWork products

Personalgrowth

Mutual

accountability

Com

plim

enta

ry

skill

s

The Team Performance CurveThe Team Performance Curve

Becoming a Real TeamBecoming a Real TeamGroups become teams through disciplined Groups become teams through disciplined action when they :action when they :

Share a common purposeShare a common purpose Agree on performance goalsAgree on performance goals Define a common workingDefine a common working approachapproach Develop high level of Develop high level of complementary skillscomplementary skills Hold themselves Hold themselves accountable for resultsaccountable for results

Recruit 10 new teammembers this year

The Goal DifferenceThe Goal DifferenceTeams thrive on performance challenges; Teams thrive on performance challenges;

they flounder without them.they flounder without them.

Activity-Based Goals

Develop a plan for communicating about childhood

obesity in the community

Short-Term GoalsOutcome-Based

Performance Goals

Reduce percent obese children in our community

AdvocateAdvocate

AdvocateAdvocate– IndividualIndividual– Able to articulate unique Able to articulate unique

experienceexperience– Able to engage others to advocate Able to engage others to advocate

for the causefor the cause– Can respond quickly to emerging Can respond quickly to emerging

issuesissues

Advocacy TeamAdvocacy Team

Common goalCommon goal– Unique talentsUnique talents

TV, radio, internet, blogging, TV, radio, internet, blogging, Meeting with legislatorsMeeting with legislatorsPublic speakingPublic speakingWriting Writing

Common GoalsCommon Goals

Spend time with group developing vision Spend time with group developing vision of what successful advocacy will “look of what successful advocacy will “look like”like”– Health care providersHealth care providers– Families and childrenFamilies and children– Schools and community Schools and community

How will you know you have been How will you know you have been successfulsuccessful– EX. Legislation passed, school policy changeEX. Legislation passed, school policy change


Unique skillsUnique skills– Organizing grass rootsOrganizing grass roots– Engaging new partnersEngaging new partners– Engaging new advocatesEngaging new advocates– Articulating goalsArticulating goals


Unique perspectivesUnique perspectives– PhysicianPhysician– NurseNurse– DentistDentist– DieticianDietician– Exercise specialist Exercise specialist


Unique connectionsUnique connections– Parents/familiesParents/families– Professional groupsProfessional groups– Community organizationsCommunity organizations– Business leaders Business leaders

Implementation and StrategyImplementation and Strategy

Core ElementsCore Elements KnowledgeKnowledge RelationshipsRelationships Leadership Team SkillsLeadership Team Skills Skills to ExecuteSkills to Execute

Example: School/Community Example: School/Community LevelLevel

Knowledge: Knowledge: School board decision makingSchool board decision making Issue knowledge (eg, finances of Issue knowledge (eg, finances of

school, history of contract)school, history of contract) Local dataLocal data Other programs that have worked Other programs that have worked

Example: School/Community Example: School/Community LevelLevel

RelationshipsRelationships School board membersSchool board members Influential familiesInfluential families PTAPTA School staff School staff

Example: School/CommunityExample: School/Community

Leadership Team Skills: Leadership Team Skills: Ability to champion issueAbility to champion issue Raise awarenessRaise awareness Gather core supportGather core support Articulate goalsArticulate goals Assemble teamAssemble team Have passion Have passion

Example: Schools CommunityExample: Schools Community

Skills to Execute:Skills to Execute: Relationship buildingRelationship building Speaking skillsSpeaking skills Media skillsMedia skills Writing skillsWriting skills Informal networking skills Informal networking skills

State versus FederalState versus FederalState Federal

Knowledge •Current policy: Who supports/opposes it?•State data on current practice•Models from other states•Cost of implementation•Benefits of implementation

•Federal lawmaking process•Background data on the issue •Federal and state level data•Cost including health impact

•Coalition partners

Relationships •Supporting state organizations (eg, PTA)•Legislators•Key constituents

•Key contacts in Congress•Potential sponsors

•Other stakeholders

State versus FederalState versus FederalState Federal

Team Skills •Ability to take issue to scale•Ability to connect multiple stakeholders•Ability to negotiate with

opposition

•Ability to speak in sound bytes•Handle controversy•Work with opponents•Work with lobbyist to manage issue•Know of stakeholders

Skills to Execute •Lobbying skills•Liaisons with stakeholder organizations•Understanding of and relationship with opposition•Ability to articulate the opposition’s concerns•Ability to create win-win scenarios

•Connect to local legislators•Stay on message•Act when needed•Media skills•Persistence

Creating An Advocacy Work Creating An Advocacy Work PlanPlan

Creating an advocacy work plan will Creating an advocacy work plan will help your team of newly trained help your team of newly trained healthcare professionals have:healthcare professionals have:– Common Purpose and DirectionCommon Purpose and Direction– Performance GoalsPerformance Goals– AccountabilityAccountability

Advocacy Work PlanAdvocacy Work Plan

Problems in need of solutionsProblems in need of solutions Focus on tangible changeFocus on tangible change

– Realistic, incremental, broadRealistic, incremental, broad Find decision makers Find decision makers Make your caseMake your case

– Communicate personally and oftenCommunicate personally and often Give and takeGive and take

– People, interests, options, criteria of successPeople, interests, options, criteria of success Keep up the good workKeep up the good work

– Perseverance, passionPerseverance, passion

AAP Advocacy Guide

Moving ForwardMoving Forward

"This isn't about inches and pounds. This "This isn't about inches and pounds. This isn't about how our kids look. That has isn't about how our kids look. That has nothing to do with that. nothing to do with that.

It's about how our kids feel, and it's about It's about how our kids feel, and it's about how they feel about themselves.“how they feel about themselves.“

Michelle ObamaMichelle Obama

February 9, 2010February 9, 2010

““Let’s Move” LaunchLet’s Move” Launch

http://www.aap.org/obesity/letsmove/index.cfm

We Can Do It!We Can Do It!

Obesity Advocacy: From Practice to Policy Sandra Hassink, MD, FAAP Chairperson, Obesity Leadership...

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