setting up camp: how do we improve nutrition, increase physical activity and prevent and control...
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Setting Up Camp: How Do We Improve Nutrition, Increase Physical Activity and
Prevent and Control Obesity?
Setting Up Camp: How Do We Improve Nutrition, Increase Physical Activity and
Prevent and Control Obesity?
William H. Dietz, MD, PhD
Division of Nutrition, Physical Activity, and Obesity
Centers for Disease Control and Prevention
William H. Dietz, MD, PhD
Division of Nutrition, Physical Activity, and Obesity
Centers for Disease Control and Prevention
DNPAO Functional ModelDNPAO Functional Model
Long-Range Planning
Research
Program Development and Technical
Assistance
Surveillance
Policy Analysis
Admin./ Clerical Services
Leadership, Management & Accountability
Training
Partnerships and External
Relations
Translation & Dissemination
Division of Nutrition, Physical Activity, and ObesityProposed October-2008
Division of Nutrition, Physical Activity, and ObesityProposed October-2008
Physical Activity and Health Branch
Mike Pratt (Acting)Lisa Kimbrough
• Research Team• Surveillance Team• Guidelines Development &
Recommendations Team
Nutrition Branch
Larry Grummer-StrawnPaulette Murphy
• Research & Surveillance Team
• Surveillance Systems Team• Guidelines Development &
Recommendations Team• International Unit (M/M)
Obesity Prevention & Control Branch
Bill Dietz (Acting)Tonya Ross)
• Research & Surveillance Team
• Guidelines Development and Recommendations Team
Associate Director for Science
Deb Galuska
Program Development & Evaluation Branch
Rosanne FarrisBecky Payne
• Program Advancement Team
• Program Development and Translation Team
• Evaluation Team
Associate Director for Translation and Dissemination
Jude McDivitt
Associate Director for Policy , Partnerships, and Communication
Vacant
Program Resource Management
Office of the DirectorBill Dietz
Laurie Johnson
Associate Director for Policy, Partnerships,
And CommunicationsVacant, GS-685-15
Policy and Partnerships TeamCasey Hannan, Team Leader (GS-685-14)
Primary Team Functions:•Coordination - legislative/policy issues•Long-range planning•Materials development: position papers, briefings, testimony, Q/A documents, etc.•Inquiry response (policymakers/partners)•FOIA•Controlled correspondence•Issues management•Partnership development
Communications TeamVacant, Team Leader (GS-1001-14)
Primary Team Functions:•Strategic communication plan•Coordination - communication activities•Audience research•Message/materials development•Web design/maintenance•Inquiry response (media/public)•Media relations•Media training & TA•Issues management
Office of Policy, Partnerships, and Communications
Overview of Efforts to Control ObesityOverview of Efforts to Control Obesity
Problem definitionStrategy development
- Targets- Strategies: policy and environmental change
Implementation- Multi-sectoral- Evaluation
Social movements
Problem definitionStrategy development
- Targets- Strategies: policy and environmental change
Implementation- Multi-sectoral- Evaluation
Social movements
0
5
10
15
20
25
30
Non-HispanicWhite
Non-HispanicBlack
MexicanAmerican
NHANES III1988-1994
NHANES2003-2006
Overweight Prevalence by Race/Ethnicity for Boys Aged 6 - 11 Years
Pre
vale
nce
(%
)
Source: Ogden CL et al.JAMA. 2008;299:2401-5; MMWR 1997; 46:199-202
0
5
10
15
20
25
Non-HispanicWhite
Non-HispanicBlack
MexicanAmerican
NHANES III1988-1994
NHANES2003-2006
Overweight Prevalence by Race/Ethnicity for Girls Aged 6 - 11 Years
Pre
vale
nce
(%
)
Source: Ogden CL et al. JAMA. 2008;299:2401-5; ;MMWR. 1997:46:199-202.
Changes in Obesity Prevalence by Race/ethnicity, Boys 2-19 Years
Changes in Obesity Prevalence by Race/ethnicity, Boys 2-19 Years
0
10
20
30
40
50
1999-2000 2001-2002 2003-2004 2005-2006
Per
cen
t
Non-Hispanic White Non-Hispanic Black Mexican American
0
10
20
30
40
50
1999-2000 2001-2002 2003-2004 2005-2006
Per
cen
t
Non-Hispanic White Non-Hispanic Black Mexican American
Ogden CL et al. JAMA 2008;299:2401
Annual Adult per Capita Cigarette Consumption and Major Smoking and Health Events – US 1900-1998
Annual Adult per Capita Cigarette Consumption and Major Smoking and Health Events – US 1900-1998
YearYear
Thousands per yearThousands per year
19001900 19101910 19201920 19301930 19401940 19501950 19601960 19701970 19801980 19901990
Great DepressionGreat Depression
End of WW IIEnd of WW II
1st Surgeon General’s report
1st Surgeon General’s report
Broadcast advertising banBroadcast advertising ban
Federal cigarettetax doubles
Federal cigarettetax doubles
Fairness Doctrinemessages on TV and radio
Fairness Doctrinemessages on TV and radio
Nonsmoker’s rightsmovement begins
Nonsmoker’s rightsmovement begins
1st smoking cancer concern1st smoking
cancer concern Surgeon General’s report onenvironmentalTobacco smoke
Surgeon General’s report onenvironmentalTobacco smoke
Master settlement agreement
Master settlement agreement
Nicotine medications Available over the counter
Nicotine medications Available over the counter
1st World Conferenceon smoking and health1st World Conference
on smoking and health
19981998
1st Great American smokeout1st Great American smokeout
Average Daily Energy Gap (kcal/day)Average Daily Energy Gap (kcal/day)
Excess Weight Gained
(Lb)Daily Energy Gap
(kcal/day)
All Teens 10 110 -165
Overweight Teens 58 678 -1,017
Behavioral implications of 150 kcal:Replacing 1 can of soda (12 oz) with water (140 kcal)Reducing TV watching by an hour (167 kcal/day)1
Walking 1.9 hours instead of sitting (for a 30-kg boy) Increasing PE from 1 to 3 times/week (240 kcal)
Wang YC et al. Pediatrics 2006;118:e1721Wiecha et al. 2006; Arch Pediatr Adolesc Med 160:436
Principal TargetsPrincipal Targets
Reduce energy intake
Decrease high and increase low ED foods
Increase fruit and vegetable intake
Reduce sugar-sweetened beverages
Decrease television time
Breastfeeding
Increase energy expenditure
Increase daily physical activity
Reduce energy intake
Decrease high and increase low ED foods
Increase fruit and vegetable intake
Reduce sugar-sweetened beverages
Decrease television time
Breastfeeding
Increase energy expenditure
Increase daily physical activity
PolicyPolicy
Laws, regulations, formal and informal rules that are adopted on a collective basis to guide individual and collective behavior
Laws, regulations, formal and informal rules that are adopted on a collective basis to guide individual and collective behavior
Strategies to Increase Fruit and Vegetable Consumption
Strategies to Increase Fruit and Vegetable Consumption
Access – supermarketsSchool and community gardensCompetitive pricingPackagingStealth interventions (Garden Market)
Access – supermarketsSchool and community gardensCompetitive pricingPackagingStealth interventions (Garden Market)
Agreement between the Alliance for a Healthier Generation and the Soft Drink
Companies
Agreement between the Alliance for a Healthier Generation and the Soft Drink
CompaniesElementary schools
H2O8 oz juice without added sweeteners FF and LF regular and flavored milk
Middle schoolsSame standards, 10 oz portions
High schoolsNo and low kcal drinks, light juices, sports drinks
50% must be H2O and no or low Kcal; 100Kcal/container
Elementary schools
H2O8 oz juice without added sweeteners FF and LF regular and flavored milk
Middle schoolsSame standards, 10 oz portions
High schoolsNo and low kcal drinks, light juices, sports drinks
50% must be H2O and no or low Kcal; 100Kcal/container
NYCDHMH, Amend Article 47, NYC Health Code; Applies to Group Day Care in NYCNYCDHMH, Amend Article 47, NYC Health Code; Applies to Group Day Care in NYC
Television, video and other visual viewing– Cannot be used for children <2 yo– Limited 60 minutes per day of educational programs
or programs that actively engage child movement for children 2+ yo
60’ physical activity requiredEliminate sugar-sweetened beveragesProvide 1% or no-fat milk
Television, video and other visual viewing– Cannot be used for children <2 yo– Limited 60 minutes per day of educational programs
or programs that actively engage child movement for children 2+ yo
60’ physical activity requiredEliminate sugar-sweetened beveragesProvide 1% or no-fat milk
Principal TargetsPrincipal Targets
Reduce energy intake
Decrease high and increase low ED foods
Increase fruit and vegetable intake
Reduce sugar-sweetened beverages
Decrease television time
Breastfeeding
Increase energy expenditure
Increase daily physical activity
Reduce energy intake
Decrease high and increase low ED foods
Increase fruit and vegetable intake
Reduce sugar-sweetened beverages
Decrease television time
Breastfeeding
Increase energy expenditure
Increase daily physical activity
Strategies to Increase Rates of BreastfeedingStrategies to Increase Rates of Breastfeeding
Maternity care practices Prenatal counselingBaby-friendly hospitals
Workplace support for breastfeedingPeer support – peer counseling Professional support and educationPublic acceptance
Maternity care practices Prenatal counselingBaby-friendly hospitals
Workplace support for breastfeedingPeer support – peer counseling Professional support and educationPublic acceptance
www.cdc.gov/breastfeeding
Role of Physical Activity in Weight ControlRole of Physical Activity in Weight Control
• Dose to prevent obesity unknown• Dose to maintain weight after loss ~ 1 hr/d• Relatively modest impact on weight loss• Reduces obesity associated comorbidities
• Dose to prevent obesity unknown• Dose to maintain weight after loss ~ 1 hr/d• Relatively modest impact on weight loss• Reduces obesity associated comorbidities
• Informational– Community-wide education– Point of decision prompts
• Behavioral and social– School-based PE– Non-family social support– Individually adapted behavior
change• Environmental and policy
– Enhanced access with outreach– Urban design and land use
• Informational– Community-wide education– Point of decision prompts
• Behavioral and social– School-based PE– Non-family social support– Individually adapted behavior
change• Environmental and policy
– Enhanced access with outreach– Urban design and land use
Effective Interventions to Promote Physical Activity
Effective Interventions to Promote Physical Activity
The RE-AIM FrameworkThe RE-AIM Framework
R ReachE EffectivenessA AdoptionI ImplementationM Maintenance
Glasgow RE et al. Ann Behav Med 2004;27:3-12
R ReachE EffectivenessA AdoptionI ImplementationM Maintenance
Glasgow RE et al. Ann Behav Med 2004;27:3-12
“To obtain more evidence-based practice we need more practice-based evidence”
Green L, Ottoson JM. In Hiss et al, From Clinical Trials to Community: the Science of Translating Diabetes and Obesity Research, NIH, 2004.
Settings for the Prevention and Treatment of Obesity
Settings for the Prevention and Treatment of Obesity
• Medical Settings• School• Work Site• Community
• Medical Settings• School• Work Site• Community
Environment
Family
School
Worksite
Community
Chronic Care Model
Medical System
Information Systems
Decision Support
Delivery System Design
Self Management Support
Family/PatientSelf-Management
Dietz WH et al. Health Affairs 2007;26:430
Pediatric InitiativesPediatric Initiatives
Expert committee recommendations
Maine and Massachusetts collaboratives
NICHQ Network (NICHQ.org)
NCQA – HEDIS measures
AAP priority – Jeanne Lindros
Expert committee recommendations
Maine and Massachusetts collaboratives
NICHQ Network (NICHQ.org)
NCQA – HEDIS measures
AAP priority – Jeanne Lindros
Environment
Family
School
Worksite
Community
Chronic Care Model
Medical System
Information Systems
Decision Support
Delivery System Design
Self Management Support
Family/PatientSelf-Management
Dietz WH et al. Health Affairs 2007;26:430
Settings for the Prevention and Treatment of Obesity
Settings for the Prevention and Treatment of Obesity
• Medical Settings• School• Work Site• Community
• Medical Settings• School• Work Site• Community
Priority Physical Activity and Nutrition Actions for Schools
Priority Physical Activity and Nutrition Actions for Schools
• Coordinated school health program and school health council
• Assessment and planning (School Health Index)
• Quality health education• Staff wellness programs
• Coordinated school health program and school health council
• Assessment and planning (School Health Index)
• Quality health education• Staff wellness programs
• Additional opportunities for physical activity (e.g., recess, after school, walk to school)
• Quality PE• Healthy school nutrition
environment
• Additional opportunities for physical activity (e.g., recess, after school, walk to school)
• Quality PE• Healthy school nutrition
environment
% of Schools in Which Students Could Purchase Selected Food and Beverages From Vending
Machines, School Store, Canteen, or Snack Bar, 2000 and 2006
% of Schools in Which Students Could Purchase Selected Food and Beverages From Vending
Machines, School Store, Canteen, or Snack Bar, 2000 and 2006
3038
21
38
27
46
11
26
14
25
0
20
40
60
80
100
Bottled water Baked goodsthat are not low
in fat
Ice cream orfrozen yogurt
that is not low infat
Salty snacksthat are not low
in fat
2% or whole milk
Perc
en
t
2000 2006
3038
21
38
27
46
11
26
14
25
0
20
40
60
80
100
Bottled water Baked goodsthat are not low
in fat
Ice cream orfrozen yogurt
that is not low infat
Salty snacksthat are not low
in fat
2% or whole milk
Perc
en
t
2000 2006
Settings for the Prevention and Treatment of Obesity
Settings for the Prevention and Treatment of Obesity
• Medical Settings• School• Work Site• Community
• Medical Settings• School• Work Site• Community
Model Worksite InterventionsModel Worksite Interventions
DNPAO StairwellsSprint campusKP farmers’ markets and commissary
policyNYC purchasing policy
DNPAO StairwellsSprint campusKP farmers’ markets and commissary
policyNYC purchasing policy
Settings for the Prevention and Treatment of Obesity
Settings for the Prevention and Treatment of Obesity
• Medical Settings• School• Work Site• Community
• Medical Settings• School• Work Site• Community
The Somerville, MA InterventionThe Somerville, MA Intervention
Increased low ED foodsDiscouraged high fat and sugar foodsSchool wellness policyEnhanced school food serviceHealthy meeting and event policyExpanded pedestrian safety policiesWalk to school campaignCity employee fitness benefitLocal physician training
Increased low ED foodsDiscouraged high fat and sugar foodsSchool wellness policyEnhanced school food serviceHealthy meeting and event policyExpanded pedestrian safety policiesWalk to school campaignCity employee fitness benefitLocal physician training
Economos et al. Obesity 2007;15:1325
Needs Identified at the CDC’s Community Meeting
Needs Identified at the CDC’s Community Meeting
Development of a national strategic planClearinghouse for obesity prevention and
control programsEvidence-based and promising interventionsTraining in HEAL for policymakersStandardized evaluation toolsFlexible comprehensive funding
Development of a national strategic planClearinghouse for obesity prevention and
control programsEvidence-based and promising interventionsTraining in HEAL for policymakersStandardized evaluation toolsFlexible comprehensive funding
Largest Connected Subcomponent in Framingham Heart Study
Christakis and Fowler. NEJM 2007;357:370
A National Convergence Around Healthy Eating, Active Living
A National Convergence Around Healthy Eating, Active Living
DNPAO and State Programs
WK Kellogg Fndtn
California Endowment
RWJF
KP’s HEAL Initiative
Steps to aHealthier US
Elements Common to Social MovementsElements Common to Social Movements
Shared and personalized perception of a threatCommon frameGrass roots commitmentSocial network focused on collective actionLocal nodes with dense social ties, linked to
other groups with weak bridging ties (rapid diffusion of innovation)
Organizational structure
Shared and personalized perception of a threatCommon frameGrass roots commitmentSocial network focused on collective actionLocal nodes with dense social ties, linked to
other groups with weak bridging ties (rapid diffusion of innovation)
Organizational structure
Paul Revere’s Rideby
David Hackett Fischer
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