Catalyzing Communities to Reduce Obesity Christina Economos, Ph.D. New Balance Chair in Childhood Nutrition Friedman School of Nutrition Science and Policy Tufts University, Boston MA February 5, 2009
U.S. Childhood Obesity National Trends 20 17.6 17 17 16 Double Quadrupled Tripled 12.4 12 11 11 10 7 7 6 5 5 5 5 4 4 0 2-5y 6-11y 12-19y 1963-1970 NHES 1971-1974 NHANES I 1976-1980 NHANES II 1988-1994 NHANES III 1999-2004 NHANES 2003-2006 NHANES
Ecological Systems Model All systems that influence human behavior must contribute and change to influence future obesity rates Global Oil crisis Food Prices Global Level Agricultural Built policies Food away Family environment Macro level from home structure Mezzo level Educational Life Big Business priorities Sedentary stress SSB, FF attractions Health care Cultural coverage values Food insecurity Advertising Urbanization & gaming
BACKGROUND • Proactive strategies required to prevent childhood obesity • Individual behaviors must be addressed in the context of societal and environmental influences • Most prevention studies target school environments • Learn from other movements (tobacco, recycling, seat belts, breastfeeding) to spark social change – Economos, C, et al. What Lessons Have Been Learned From Other Attempts To Guide Social Change? Nutrition Reviews 2001; 59(3):40-56 • Community-based interventions that have a theoretical framework and are mutli-level and participatory in nature are needed: SUS, Be Active Eat Well, EPODE – Huang, T and
What can we do? Work in Communities There’s strength in numbers! Source: Institute of Medicine, Preventing Childhood Obesity: Health in the Balance, 2005
Shape Up Somerville: Eat Smart. Play Hard. • A community-based, participatory, environmental approach to prevent childhood obesity • A 3 year controlled trial to study 1st – 3rd grade culturally and ethnically diverse children and their parents from 3 cities outside Boston • Goals: – To examine the effectiveness of the model on the prevention of undesirable weight gain in children – Transform a community and inform social change at the national level R06/CCR121519-01 from the Centers for Disease Control and Prevention. Additional support by Blue Cross Blue Shield of Massachusetts, United Way of Mass Bay, The US Potato Board, Stonyfield Farm, and Dole Foods
CBPR • Community-based participatory research (CBPR) includes a collaborative partnership with the community in all phases of the research: – identifying the problem – designing, implementing and evaluating the intervention – building community capacity – identifying how data informs actions to improve health within the community Potential to influence cultural and social norms
Study Post School Year 1 Timeline Measurement Post School Year 2 May 04 Pre School Measurement Baseline Year 2 May 05 Pre School Year 1 Measurement Measurement Sept 04 Oct 03 Summer Planning and Year 1 Year 2 monitoring year Intervention Intervention Oct 02-Sept 03 Oct 03-Sept 04 Oct 04-Sept 05
Study Subject Numbers Eligible students Consented to participate N=5940 N=1721 Pre/Post Year 1 (Oct 03-May 04) N=1178 Pre/Post Year 2 (Oct 04-May 05) N=1100 Pre/Post Years 1 & 2 (Oct 03-May 05) N=1034
Baseline Overweight/Obesity 30 25 20 Overweight 15 Obesity 10 5 0 U.S. Intervention Control 1 Control 2 At risk: 85 th to < 95 th percentile Overweight: 95 th percentile Ogden JAMA 2006, Economos, 2003 Reference: CDC 2000
INTERVENTION • Designed to increase energy expenditure (EE) of up to 125 kcals per day beyond the increases in EE and energy intake that accompany growth – Variety of increased opportunities for physical activity – < 2 hr. per day of Screen Time, No TV in bedroom – Increased availability of foods of lower energy density, emphasizing fruits, vegetables, whole grains, and low-fat dairy – Foods high in fat and sugar were discouraged – Family Meals encouraged – structure, modeling, education, emotional connection: practice as often as possible • Multi-level approach: – Before, during, after school, home, community
Early Morning At Home Before School Program Home: Environment Safe Routes to School Maps Healthier School Breakfast Walking to School (-30 kcals) Fiber , Sugar , Fat School: Parent, Child, Family Healthier Home Breakfast Appropriate Portion Sizes Child, teachers, administration, staff Fiber , Sugar , Fat Increased Fresh Fruits (~25 kcals) Appropriate Portion Sizes Breakfast Coordinator During School Physical Activity Equipment for Recess Classroom Micro Units Physical Activity (- 25 kcals) Physical Activity (- 25 kcals) 5 days/wk (10 min) Environment Nutrition & Physical Activity Education 1 day/wk Healthier School Lunch (30 min) Fiber, Sugar, Fat School: School: Healthier Fundraising Alternatives Increased Fresh Fruits & Vegetables Child, teachers, administration, staff Appropriate Portion Sizes Child, teachers, administration, staff Improved Presentation and Atmosphere Professional Development Social Marketing in Cafeteria Teachers Alternative “ Healthier ” A La Carte Items Administrators New Food Service Equipment Food Service Staff PE Teachers Afternoon At home After School Program Environment Home: Safe Routes to School Maps Curriculum: Community: Walking Home (-30 kcals) Cooking Lessons Parent, Child, Family After school programs Healthy Home Snack Physical Activity (-30 kcals) Fiber, Sugar, Fat Nutrition Education Professional Development Community: Ethnic groups Home Environment (~15 kcal) Community Environment Home: Community “ Champions ” Parent Newsletter w/ coupons Growth Reports Restaurant Participation Reinforcing Parent, Child, Family Health Care System Screen Time Pediatrician Training & Support Environments Promotional Gifts Community TV Appearances Local Government Ethnic Group Outreach Community PA Resource Guide Community: Restaurants Community Events Media
Skills Development
Experiential Learning
Demonstrations
A La Carte Options: Before Shape Up….
After…Improved A La Carte Options
HEAT Club: After School Program
Before school : Walking School Bus
Support from Community Champions Visible role models • Mayor Joe Curtatone • Aldermen • School Committee Members
Growing food, knowing food School Gardens and Nutrition Education
SUS Approved Restaurants
Shape Up Somerville : Results • Engaged 90 teachers in 100% of 1-3 grade classrooms (N=81) • Participated in or conducted 100 community events and 4 parent forums • Trained 50 medical professionals • Recruited 21 restaurants • Reached 811 families through 9 parent newsletters, and 353 community partners through 6 community newsletters • Reached over 20,000 through a monthly media piece (11 months) • Recruited all 14 after-school programs • Developed community-wide policies to promote and sustain change
City Wide Policy Changes • School Department – Wellness policy, snack policies, classroom curriculum • Food Service Department – Union negotiations, fresh produce, • After School Curriculum • Walkability – Thermoplastic crosswalks, bikeracks • Research – YRBS, weight screening, • City Employee Wellness – $200 reimbursement
RESULTS: BMI z-score at 4 time points Control 1 & 2 Year 1 Change Intervention vs. Control 1 + 2 Estimate -0.1005 P = 0.0011 N = 1178 Obesity 2007;15:1325-1336 N = 922
First Year Results Economos C , Hyatt R, Goldberg J, Must A, Naumova E, Collins J, Nelson M. A Community-Based Environmental Change Intervention Reduces BMI z-Score in Children: Shape Up Somerville First Year Results. Obesity. 2007;15:1325-1326.
Results: Pre-Post Summer BMI z-score N=1120
Overweight and Obesity Over 2 Years (N=1034) 15 OR= 2.25 P=0.023 11.6 11.6 12 10.5 OR = 0.72 9 P=0.007 % Control 5.4 Intervention 5.3 6 1.8 3 0 Prevelance Incidence Remission
School Nutrition Policy Initiative: Results Figure 1: Unadjusted incidence, remission, and prevalence of overweight (85.0 th - 94.9 th percentiles) at 2 years. Statistically significant differences between the intervention and control schools after controlling for race/ethnicity, gender, age, and baseline prevalence for the prevalence outcome. Foster, G. 2008 Pediatrics; 121;e794-e802
Weight status in Children by Birth Place of Mother Baseline (Oct’03) Mother Born in US Mother NOT born in US Between Groups N mean (sd) N mean (sd) t-score p-value BMI 601 17.7445 (3.062) 398 18.35 (3.724) -2.692 0.007 BMI z 599 .699 (.953) 396 .7922 (1.101) -1.378 0.169 Two School Years with an Intervening Summer (Oct'03-May'05) in Controls Mother Born in US Mother NOT born in US Between Groups N mean difference (sd) p-value N mean difference (sd) p-value t-score p-value BMI 341 1.244 (1.43) <.0001 184 1.512 (1.533) <.0001 -1.998 0.046 BMI z 339 .039 (.381) 0.06 183 .075 (.343) 0.004 -1.067 0.287 These data indicate an increase in weight gain in children with immigrant mothers and underscore the urgent need to develop specific strategies to help this population
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