minnesota studies of health education and environmental

Minnesota Studies of Health Education and Environmental

Approaches to Obesity Treatment and Prevention

Minnesota Studies of Health Education and Environmental

Approaches to Obesity Treatment and Prevention

Robert W. Jeffery, Ph.D.University of Minnesota

USA

Robert W. Jeffery, Ph.D.University of Minnesota

USA

Prevalence of Obesity (BMI ≥ 30) in US Adults, 1960-2000

Flegel et al., 2002

05

101520253035

1960 1970 1980 1990 2000

MenWomen

Perc

ent

Perc

ent

Prevalence of Obesity (BMI ≥ 30) in US Adults, 1960-2000 by Age

Flegel et al., 2002

0

10

20

30

40

1960 1970 1980 1990 2000

20-39 yrs40-59 yrs60-74 yrs

Perc

ent

Perc

ent

Prevalence of Overweight in US Children, 1970-2000

Ogden et al., 2002

0

5

10

15

20

1970 1980 1990 2000

2-5 yrs6-11 yrs12-19 yrs

Perc

ent

Perc

ent

05

1015202530

1970 1980 1990 1999

Total energyTotal fatTotal CHO

From USDA

Percent change in per capita disappear-ance of total energy, total fat, and total CHO in the US, 1970-99.

Percent change in per capita disappear-ance of total energy, total fat, and total CHO in the US, 1970-99.

% C

hang

e

What Can Be Done About the Obesity Epidemic?

What Can Be Done About the Obesity Epidemic?

! Better education about eating and exercise.

! Reduce environmental exposures that promote overeating and under-exercising.

The Healthy Worker Project (HWP)

The Healthy Worker Project (HWP)

A randomized trial of worksite interventions for

weight loss.

Jeffery et al, 1993

-1.00-0.75-0.50-0.250.000.250.500.751.00

Baseline Follow-up

Treatment

Control

HWP: Mean change in BMI over 2 years.HWP: Mean change in BMI over 2 years.

Controlling for age, sex, and education.Jeffery et al, 1993

BM

I cha

nge

Minnesota Heart Health Program (MHHP)

Minnesota Heart Health Program (MHHP)

A 10-year research and demonstration project to evaluate the

effectiveness of multicomponentinterventions to reduce CVD

incidence and mortality

Luepker et al, 1994

25.0025.2525.5025.7526.0026.2526.5026.7527.00

-3 -2 -1 0 1 2 3 4 5 6 7

ComparisonEducation

Mean BMI in MHHP education and comparison communities by year: Cross-sectional surveys.Mean BMI in MHHP education and comparison communities by year: Cross-sectional surveys.

BM

IB

M I

B(3) B(2) B(1) B0 E1 E2 E3 E4 E5 E6 E7B(3) B(2) B(1) B0 E1 E2 E3 E4 E5 E6 E7

B and E YearsB and E YearsJeffery et al, 1995

Pound of Prevention (POP)

Pound of Prevention (POP)

Randomized trial evaluating the effectiveness of a low-cost

educational approach in reducing the rate of weight

gain with age.Jeffery et al, 1999

Weight change (lb) by treatment group by year.Weight change (lb) by treatment group by year.

0

1

2

3

4

5

Baseline Year 1 Year 2 Year 3

ControlNewsletterNewsletter + Incentive

Adjusted means, controlling for age, sex, type, education, and ∆ smoking. Jeffery et al, 1999

Weigh-To-BeWeigh-To-Be

A randomized trial of mail and phone interventions for

weight loss in a managed care setting.

Jeffery, 2003

Weigh-To-Be Participant Characteristics

Weigh-To-Be Participant Characteristics

! 1801 MCO members with BMI ≥ 27.0

! Recruited by direct mail, clinic flyers, and physician referral

! 72% women

! Mean BMI = 33.6

Weigh-To-Be TreatmentsWeigh-To-Be Treatments

! Usual care

! 10 phone counseling lessons

! 10 interactive lessons by mail

Weigh-To-Be EvaluationWeigh-To-Be Evaluation

! Clinic visits at baseline and 24 months

! Mailed surveys at 6, 12, and 18 months

Weigh-To-Be Weight Loss ResultsWeigh-To-Be Weight Loss Results

-4

-3

-2

-1

0

1

2

Baseline 6 months 12 months 24 months

ControlMailPhone

Wei

ght l

oss

(kg)

Wei

ght l

oss

(kg)

Cafeteria Study of Price and Availability Influences on Fruit and

Salad Consumption

Cafeteria Study of Price and Availability Influences on Fruit and

Salad Consumption

! Three (3) weeks baseline observation! Three (3) weeks interventions

" 50% price reduction" increased choices

! Three (3) weeks return to baseline

Jeffery et al, 1994

0

10

20

30

40

50

0 3 6 9 12 15 18 21 24 27 30 33 36 39 42 45

DayDay

BaselineBaseline InterventionIntervention Follow-upFollow-up

X = 11X = 11 X = 31X = 31 X = 14X = 14Num

ber o

f Fru

it Pu

rcha

ses

Num

ber o

f Fru

it Pu

rcha

ses

Jeffery et al, 1994

0

10

20

30

40

50

0 3 6 9 12 15 18 21 24 27 30 33 36 39 42 45

DayDay

Poun

ds o

f Sal

ad

Purc

hase

dPo

unds

of S

alad

Pu

rcha

sed

BaselineBaseline InterventionIntervention Follow-upFollow-up

X = 8X = 8 X = 24X = 24 X = 12X = 12

Jeffery et al, 1994

020406080

100

Average School 1urban

School 2Suburban

Baseline 1Low priceBaseline 2

Fruit Sales as a Function of PriceFruit Sales as a Function of Price

Average versus each school

French et al, 1997

Mea

n w

eekl

y fr

uit s

ales

01020304050

%

Same price 50% low-fat

discount

Same price

Low-Fat Snack Sales in Vending Machines (%) as a Function of PriceLow-Fat Snack Sales in Vending

Machines (%) as a Function of Price

French et al, 1997

Equal -10% -25% -50%Equal -10% -25% -50%

WorksiteWorksiteSchoolSchool

NoneNone

Low-FatLabel

Low-FatLabel

Label +Sign

Label +Sign

Prom

otio

n

Price

Setti

ng

CHIPS Study DesignCHIPS Study Design

0

5

10

15

20

25

No Label Label Label & Sign

PromotionPromotion

% S

ales

LF

Snac

ksEffect of Health Promotion on

Low-Fat Snack SalesEffect of Health Promotion on

Low-Fat Snack Sales

% Increase in sales: 1% 8%

French et al, 2001

05

10152025

Equal -Ź10% -Ź25% -Ź50%% S

ales

LF

Snac

ks

Price% Increase in sales: 9% 39% 93%

Effect of Price on Low-Fat Snack Sales

Effect of Price on Low-Fat Snack Sales

French et al, 2001

1. Free gym membership to University employees: NO EFFECT!

2. Free gym membership to 616 weight gain prevention study participants: 2 USED THEM�!

Results of Two Studies on the Effects of Price on the Use of Exercise Facilities

Results of Two Studies on the Effects of Price on the Use of Exercise Facilities

French, et al 1994

Sherwood, et al 1998

13.8c15.5b

12.7a

11.1a

0

5

10

15

20

NoIntervention

Signs Signs +Music +Artwork

NoIntervention

% P

eopl

e U

s in g

th

e S t

a irs

Percentage of People Using the Stairs During Each Phase of the Study

Percentage of People Using the Stairs During Each Phase of the Study

NOTE: Percentages with unshared superscripts differ significantly, p < .05 Boutelle et al, 2002

TACOSTACOS

A two-year group randomized trial evaluating the effects of environmental and promotional interventions on student purchases of lower fat food served a la carte and in vending machines.

French 2003

TACOS SchoolsTACOS Schools

! 10 treatment, 10 control

! Median students/school: 1,731

TACOS InterventionTACOS Intervention

! Increase offerings of lower fat a la carte foods.

! Student led promotions for lower fat foods.

TACOS: Most commonly available a la carte foods.

TACOS: Most commonly available a la carte foods.

% of total Number of Category food item schoolsChips/crackers 11.5 19Entrees 10.0 14Ice cream 9.9 20Cookies (packaged) 8.7 18Pastry (school prepared) 5.5 16Pastry (packaged) 5.4 17Cookies (school prepared) 5.3 17Candy 4.8 10Fruits/vegetables 4.5 1735.4% of products low fat (5.5 gm per serving)

TACOS: Vending MachinesTACOS: Vending Machines

Median per school

Total 12Snack 2Soft drink 4Others 5

35.0% of products low fat (5.0 gm per serving)

ConclusionsConclusions! Nutrition education is not a very effective

method for reducing population obesity.

! Behavior changes associated with environmental approaches are encouraging.

! Effectiveness of environmental interventions in changing weight need experimental study.

! Ignorance: We�re not sure how we got here and thus aren�t sure how to get back.

! Value Conflicts: Social and economic consequence of solutions won�t please everyone.

! Lack of Social Consensus:" On the urgency of the problem." On necessary steps towards its resolution.

Obstacles to Effective Public PolicyObstacles to Effective Public Policy

Public Opinion on Who Is Responsible for Today�s Diet-Related Problems

(n = 821)

Public Opinion on Who Is Responsible for Today�s Diet-Related Problems

(n = 821)

! Individuals 80%

! Stores 2%

! Manufacturers 14%

Jeffery et al, 1990