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Promising Efforts to Combat Childhood Obesity? William H. Dietz, M.D., Ph.D. Division of Nutrition and Physical Activity Centers for Disease Control and Prevention and Physical Activity Centers for Disease Control and Prevention

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Page 1: Promising Efforts to Combat Childhood Obesity? - NIHCM · Promising Efforts to Combat Childhood Obesity? William H. Dietz, ... Evaluation. Overweight ... Obesity.” Institute of

Promising Efforts to CombatChildhood Obesity?

William H. Dietz, M.D., Ph.D.

Division of Nutrition and Physical Activity

Centers for Disease Control and Preventionand Physical Activity

Centers for Disease Control and Prevention

Page 2: Promising Efforts to Combat Childhood Obesity? - NIHCM · Promising Efforts to Combat Childhood Obesity? William H. Dietz, ... Evaluation. Overweight ... Obesity.” Institute of

Disclaimer

The findings and conclusions in thisreport have not been formallydisseminated by the Centers forDisease Control and Prevention andshould not be construed to representany agency determination or policy.

Page 3: Promising Efforts to Combat Childhood Obesity? - NIHCM · Promising Efforts to Combat Childhood Obesity? William H. Dietz, ... Evaluation. Overweight ... Obesity.” Institute of
Page 4: Promising Efforts to Combat Childhood Obesity? - NIHCM · Promising Efforts to Combat Childhood Obesity? William H. Dietz, ... Evaluation. Overweight ... Obesity.” Institute of

Adult per Capita Cigarette Consumption andMajor Environmental and Policy Changes in

the US 1900-1990

Year

Thousands peryear

1900 1910 1920 1930 1940 1950 1960 1970 1980 1990

Great Depression

End ofWW II

US Surgeon General’s first report

Broadcastadvertising ban

Federal cigarettetax doubles

First Medical reportslinking smoking and cancer

Fairness Doctrinemessages on radio

and televisionNonsmoker’s rightsmovement begins

Page 5: Promising Efforts to Combat Childhood Obesity? - NIHCM · Promising Efforts to Combat Childhood Obesity? William H. Dietz, ... Evaluation. Overweight ... Obesity.” Institute of

Lessons from Tobacco Control

Surveillance – advocacy and policyComprehensive, multidimensionalEfficacy and effectiveness researchAdvocacy frames the issueFunded programsExplicit, measurable goals and objectivesThreshold spendingLocal initiatives fed national action

Page 6: Promising Efforts to Combat Childhood Obesity? - NIHCM · Promising Efforts to Combat Childhood Obesity? William H. Dietz, ... Evaluation. Overweight ... Obesity.” Institute of

Overview of Efforts to Control Obesityand Other Chronic Diseases

Problem Definition Assessment Prevalence Disease burden

Strategy Development Social Ecologic Model Evidence development Translation

Implementation State Programs, Steps Policy/environmental Interventions Media

Evaluation

Page 7: Promising Efforts to Combat Childhood Obesity? - NIHCM · Promising Efforts to Combat Childhood Obesity? William H. Dietz, ... Evaluation. Overweight ... Obesity.” Institute of

Overweight Prevalence by Race/Ethnicity for Adolescent Boys Aged 12 - 19 Years

Perc

enta

ge

Source: JAMA, 2004;291:2847

Page 8: Promising Efforts to Combat Childhood Obesity? - NIHCM · Promising Efforts to Combat Childhood Obesity? William H. Dietz, ... Evaluation. Overweight ... Obesity.” Institute of

Overweight Prevalence by Race/Ethnicity for Adolescent Girls Aged 12 - 19 Years

Source: JAMA, Oct. 9, 2002, Vol. 288, No. 14:1731

Perc

enta

ge

Page 9: Promising Efforts to Combat Childhood Obesity? - NIHCM · Promising Efforts to Combat Childhood Obesity? William H. Dietz, ... Evaluation. Overweight ... Obesity.” Institute of

Consequences of Childhoodand Adolescent Obesity

Common Uncommon•Growth•Psychosocial•Hyperlipidemia•Hepatic steatosis•Abnormal glucose metabolism•Asthma•Persistence into adulthood

•Hypertension

•Sleep apnea

•Pseudotumor

•PCOD

•Cholelithiasis

•Orthopedic

Page 10: Promising Efforts to Combat Childhood Obesity? - NIHCM · Promising Efforts to Combat Childhood Obesity? William H. Dietz, ... Evaluation. Overweight ... Obesity.” Institute of

BMI and Distribution of Morbid Obesity

BMI @99%tile* > BMI 40** % > 99%tileMales 16yo 33.9 1.6% 8.1% 17yo 34.4 0.3% 6.4% 18yo 35.0 0.1% 3.6%

Females 16yo 39.1 1.6% 1.6% 17yo 40.8 2.3% 2.0% 18yo 42.9 1.7% 0.7%

*CDC growth charts **NHANES 1999-2002

Page 11: Promising Efforts to Combat Childhood Obesity? - NIHCM · Promising Efforts to Combat Childhood Obesity? William H. Dietz, ... Evaluation. Overweight ... Obesity.” Institute of

Overview of Efforts to Control Obesityand Other Chronic Diseases

Problem Definition Assessment Prevalence Disease burden

Strategy Development Social Ecologic Model Evidence development Translation

Evaluation

Implementation State Programs, Steps Policy/environmental Interventions Media

Page 12: Promising Efforts to Combat Childhood Obesity? - NIHCM · Promising Efforts to Combat Childhood Obesity? William H. Dietz, ... Evaluation. Overweight ... Obesity.” Institute of

A Public Health Framework to Prevent and Control Overweightand Obesity

Energy Intake Energy Expenditure

Energy Balance

Prevention of Overweight and ObesityAmong Children, Adolescents, and Adults

Note: Adapted from“Preventing ChildhoodObesity.” Institute ofMedicine, 2005.

IndividualFactors

BehavioralSettings

Social Normsand Values

Home andFamily

School

Community

Work Site

Healthcare

Genetics

Psychosocial

Other PersonalFactors

Food andBeverage Industry

Agriculture

Education

Media

Government

Public HealthSystems

HealthcareIndustry

Business andWorkers

Land Use andTransportation

Leisure andRecreation

Community- andFaith-basedOrganizations

Foundations andOther Funders

Food and Beverage Intake

Physical Activity

Sectors ofInfluence

Page 13: Promising Efforts to Combat Childhood Obesity? - NIHCM · Promising Efforts to Combat Childhood Obesity? William H. Dietz, ... Evaluation. Overweight ... Obesity.” Institute of

Principal Targets

Reduce energy intakeIncrease low ED foodsReduce sugar-sweetened beveragesReduce television timeReduce portion size

Increase energy expenditureIncrease daily physical activity

Breastfeeding

Page 14: Promising Efforts to Combat Childhood Obesity? - NIHCM · Promising Efforts to Combat Childhood Obesity? William H. Dietz, ... Evaluation. Overweight ... Obesity.” Institute of

Strategies to Increase Fruitand Vegetable Consumption

Early exposureAccessCommunity and school gardensFarmers’ MarketCompetitive pricingStealth interventions (Garden Market)

Page 15: Promising Efforts to Combat Childhood Obesity? - NIHCM · Promising Efforts to Combat Childhood Obesity? William H. Dietz, ... Evaluation. Overweight ... Obesity.” Institute of

Agreement between the Alliance for a HealthierGeneration and the Soft Drink Companies

Elementary schoolsH2O8 oz juice without added sweetenersFF and LF regular and flavored milk

Middle schoolsSame standards, 10 oz portions

High schoolsNo and low kcal drinks, light juices, sports drinks50% must be H2O and no or low Kcal;100Kcal/container

Page 16: Promising Efforts to Combat Childhood Obesity? - NIHCM · Promising Efforts to Combat Childhood Obesity? William H. Dietz, ... Evaluation. Overweight ... Obesity.” Institute of

Policy/LegislationNYCDHMH, 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 engagechild movement for children 2+ yo

60’ physical activity requiredEliminate sugar-sweetened beveragesProvide low or no-fat milk

Page 17: Promising Efforts to Combat Childhood Obesity? - NIHCM · Promising Efforts to Combat Childhood Obesity? William H. Dietz, ... Evaluation. Overweight ... Obesity.” Institute of

Principal Targets

Reduce energy intakeIncrease low ED foodsReduce sugar-sweetened beveragesReduce television timeReduce portion size

Increase energy expenditureIncrease daily physical activity

Breastfeeding

Page 18: Promising Efforts to Combat Childhood Obesity? - NIHCM · Promising Efforts to Combat Childhood Obesity? William H. Dietz, ... Evaluation. Overweight ... Obesity.” Institute of

Effective Interventions to PromotePhysical Activity

• 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

Page 19: Promising Efforts to Combat Childhood Obesity? - NIHCM · Promising Efforts to Combat Childhood Obesity? William H. Dietz, ... Evaluation. Overweight ... Obesity.” Institute of

Principal Targets

Reduce energy intakeIncrease low ED foodsReduce sugar-sweetened beveragesReduce television timeReduce portion size

Increase energy expenditureIncrease daily physical activity

Breastfeeding

Page 20: Promising Efforts to Combat Childhood Obesity? - NIHCM · Promising Efforts to Combat Childhood Obesity? William H. Dietz, ... Evaluation. Overweight ... Obesity.” Institute of

Strategies to Increase Rates ofBreastfeeding

Maternity care practicesPrenatal counselingBaby-friendly hospitals

Workplace support for breastfeedingPeer support – peer counselingProfessional support and educationPublic acceptance

Shealy et al. Breastfeeding Interventions: www.cdc.gov/breastfeeding

Page 21: Promising Efforts to Combat Childhood Obesity? - NIHCM · Promising Efforts to Combat Childhood Obesity? William H. Dietz, ... Evaluation. Overweight ... Obesity.” Institute of

Overview of Efforts to Control Obesityand Other Chronic Diseases

Problem Definition Assessment Prevalence Disease burden

Evaluation

Strategy Development Social Ecologic Model Evidence development Translation

Implementation State Programs, Steps Policy/environmental Interventions Media

Page 22: Promising Efforts to Combat Childhood Obesity? - NIHCM · Promising Efforts to Combat Childhood Obesity? William H. Dietz, ... Evaluation. Overweight ... Obesity.” Institute of

Settings for the Prevention and Treatment of Obesity

• Industry

• Medical Settings

• School

• Work Site

• Community

Page 23: Promising Efforts to Combat Childhood Obesity? - NIHCM · Promising Efforts to Combat Childhood Obesity? William H. Dietz, ... Evaluation. Overweight ... Obesity.” Institute of

Chronic Care ModelEnvironment Medical System

Family

School

Worksite

Community

Family/PatientSelf-Management

Information Systems

Decision Support

Delivery System Design

Self Management Support

Page 24: Promising Efforts to Combat Childhood Obesity? - NIHCM · Promising Efforts to Combat Childhood Obesity? William H. Dietz, ... Evaluation. Overweight ... Obesity.” Institute of
Page 25: Promising Efforts to Combat Childhood Obesity? - NIHCM · Promising Efforts to Combat Childhood Obesity? William H. Dietz, ... Evaluation. Overweight ... Obesity.” Institute of

Chronic Care ModelEnvironment Medical System

Family

School

Worksite

Community

Family/PatientSelf-Management

Information Systems

Decision Support

Delivery System Design

Self Management Support

Page 26: Promising Efforts to Combat Childhood Obesity? - NIHCM · Promising Efforts to Combat Childhood Obesity? William H. Dietz, ... Evaluation. Overweight ... Obesity.” Institute of

BCBS of MassachusettsEcological Approach

Community Community Based GrantsPeer LeaderTrainingVolunteer Outreach TrainingChildren’s Museum ExhibitCoalition Partnerships

SchoolHealthy Choices Middle GrantsAnnual Conference Teacher ToolkitBest in Class Awards

HealthcareClinician Toolkit Medscape BMI CME Treatment Program Grants PCP Incentive Program NICHQ Physician Collaborative

FamilyParent Toolkit Parent Advocacy WorkshopWorksite Seminar 2’sDays Challenge

MediaMillion Ways Contest Million Reasons Contest CBS-TV4 CampaignWBOS/MIX Radio Contest

Page 27: Promising Efforts to Combat Childhood Obesity? - NIHCM · Promising Efforts to Combat Childhood Obesity? William H. Dietz, ... Evaluation. Overweight ... Obesity.” Institute of

Pediatric Initiatives

CDC/AMA/HRSA support forExpert Committee

Maine and Massachusettscollaboratives

NICHQ Summit – networkdevelopment

Page 28: Promising Efforts to Combat Childhood Obesity? - NIHCM · Promising Efforts to Combat Childhood Obesity? William H. Dietz, ... Evaluation. Overweight ... Obesity.” Institute of

Settings for the Prevention and Treatment of Obesity

• Industry

• Medical Settings

• School

• Work Site

• Community

Page 29: Promising Efforts to Combat Childhood Obesity? - NIHCM · Promising Efforts to Combat Childhood Obesity? William H. Dietz, ... Evaluation. Overweight ... Obesity.” Institute of

Potential Effect of Urban Form on Obesityand Other Chronic Diseases

Urban Form

PhysicalActivityleisuretransportationoccupationalhousehold

Obesity andother chronicdiseases

Adapted from Ewing et al; Am J Health Prom 2003; 18:47

Food accessFood quality

Page 30: Promising Efforts to Combat Childhood Obesity? - NIHCM · Promising Efforts to Combat Childhood Obesity? William H. Dietz, ... Evaluation. Overweight ... Obesity.” Institute of

Successful Community-basedInterventions for Children

• El Paso Texas(Paso del Norte HealthFoundation)

• Somerville Massachusetts• Colac (Australia)• EPODE (Ensemble Prevenons

L’Obesite des Enfants – FleurbaixLaventie, FR)

Page 31: Promising Efforts to Combat Childhood Obesity? - NIHCM · Promising Efforts to Combat Childhood Obesity? William H. Dietz, ... Evaluation. Overweight ... Obesity.” Institute of

Paso del Norte El Paso Project

• CATCH in elementary schools (Coordinated Approach to ChildHealth)

• Bike/walk paths• Walk El Paso• Que Sabrosa Vida

Page 32: Promising Efforts to Combat Childhood Obesity? - NIHCM · Promising Efforts to Combat Childhood Obesity? William H. Dietz, ... Evaluation. Overweight ... Obesity.” Institute of

Changes in the Prevalence of Overweight:Paso del Norte El Paso Project

2001-02 2004-054th grade 26% 23%8th grade 19% 15%

Page 33: Promising Efforts to Combat Childhood Obesity? - NIHCM · Promising Efforts to Combat Childhood Obesity? William H. Dietz, ... Evaluation. Overweight ... Obesity.” Institute of

What HEAL Looks Like in California

• KP’s HEAL-CHI– Locations: Richmond, Santa

Rosa, Modesto– Investment: $1.5M per

site/5years• Healthy Eating, Active

Communities (HEAC)– Multi-level & multi-sectoral– Health sector leadership– Community engagement &

ownership– Evidence informed– Focus on disparities

Page 34: Promising Efforts to Combat Childhood Obesity? - NIHCM · Promising Efforts to Combat Childhood Obesity? William H. Dietz, ... Evaluation. Overweight ... Obesity.” Institute of

Overview of Efforts to Control Obesityand Other Chronic Diseases

Problem Definition Assessment Prevalence Disease burden

Evaluation

Strategy Development Social Ecologic Model Evidence development Translation

Implementation State Programs, Steps Policy/environmental Interventions Media

Page 35: Promising Efforts to Combat Childhood Obesity? - NIHCM · Promising Efforts to Combat Childhood Obesity? William H. Dietz, ... Evaluation. Overweight ... Obesity.” Institute of

“To obtain more evidence-basedpractice we need more practice-based evidence”

Greeen L, Ottoson JM. In Hiss et al, From Clinical Trialsto Community: the Science of Translating Diabetes andObesity Research, NIH, 2004.

Page 36: Promising Efforts to Combat Childhood Obesity? - NIHCM · Promising Efforts to Combat Childhood Obesity? William H. Dietz, ... Evaluation. Overweight ... Obesity.” Institute of

Obesity Prevention Requires AllSectors

of Influence Working Together

Agriculture

Schools

Trans-portation

LandUse

Food & Beverage Industry

MedicalSystem

WorkSite

Media

Community

Science Base

For Obesity Prevention

Active Livingand

Healthy Eating

Page 37: Promising Efforts to Combat Childhood Obesity? - NIHCM · Promising Efforts to Combat Childhood Obesity? William H. Dietz, ... Evaluation. Overweight ... Obesity.” Institute of

Potential Foundation Investmentsfor Weight Control

Convene networks or coalitions – multiple sectorsGenerate local dataAddress disparitiesSupport evaluationAdvocateReframe the problem

Grantmakers in Health. Reversing the Obesity Epidemic. Issue Brief28, 2/2007.

Page 38: Promising Efforts to Combat Childhood Obesity? - NIHCM · Promising Efforts to Combat Childhood Obesity? William H. Dietz, ... Evaluation. Overweight ... Obesity.” Institute of

References

cdc.gov/nccdphp/dnpacdc.gov/nccdphp/dashcdc.gov/breastfeedingnichq.org

Page 39: Promising Efforts to Combat Childhood Obesity? - NIHCM · Promising Efforts to Combat Childhood Obesity? William H. Dietz, ... Evaluation. Overweight ... Obesity.” Institute of

The RE-AIM Framework

R ReachE EffectivenessA AdoptionI ImplementationM Maintenance

Glasgow RE et al. Ann Behav Med 2004;27:3-12


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