BRIDGING THE EVIDENCE GAP IN OBESITY PREVENTION

A FRAMEWORK TO INFORM DECISION MAKING

Committee on an Evidence Framework for Obesity Prevention Decision Making

Food and Nutrition Board

Shiriki K. Kumanyika, Lynn Parker, and Leslie J. Sim, Editors

INSTITUTE OF MEDICINE
OF THE NATIONAL ACADEMIES

THE NATIONAL ACADEMIES PRESS

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BRI DGI NG TH E EVI DENCE GAP I N OBESITY PREVENTION A FRAMEWORK TO INFORM DECISION MAKING Committee on an Evidence Framework for Obesity Prevention Decision Making Food and Nutrition Board Shiriki K. Kumanyika, Lynn Parker, and Leslie J. Sim, Editors

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THE NATIONAL ACADEMIES PRESS 500 Fifth Street, N.W. Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. This study was supported by Tracking No. 20604633 between the National Academy of Sciences and Kaiser Permanente; by Grant No. 61747 with the Robert Wood Johnson Foundation; and by Contract No. 200-2005-13434, Task Order 13 with the Centers for Disease Control and Prevention. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the view of the organizations or agencies that provided support for this project. Library of Congress Cataloging-in-Publication Data Bridging the evidence gap in obesity prevention : a framework to inform decision making / Committee on an Evidence Framework for Obesity Prevention Decision Making, Food and Nutrition Board ; Shiriki K. Kumanyika, Lynn Parker, and Leslie J. Sim, editors. p. ; cm. ISBN 978-0-309-14989-1 (pbk.)—ISBN 978-0-309-14990-7 (pdf) 1. Obesity— Prevention. 2. Evidence-based medicine. 3. Outcome assessment (Medical care) I. Kumanyika, Shiriki Kinika, 1945- II. Parker, Lynn. III. Sim, Leslie J. IV. Institute of Medicine (U.S.). Committee on an Evidence Framework for Obesity Prevention Decision Making. V. Institute of Medicine (U.S.). Food and Nutrition Board. [DNLM: 1. Obesity—prevention & control. 2. Decision Making, Organizational. 3. Outcome and Process Assessment (Health Care) 4. Program Evaluation. WD 210 B851 2010] RA645.O23B75 2010 362.196′398—dc22 2010023392 Additional copies of this report are available from the National Academies Press, 500 Fifth Street, N.W., Lockbox 285, Washington, DC 20055; (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area); Internet, http://www.nap.edu. For more information about the Institute of Medicine, visit the IOM home page at: www. iom.edu. Copyright 2010 by the National Academy of Sciences. All rights reserved. Printed in the United States of America The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin. Suggested citation: IOM (Institute of Medicine). 2010. Bridging the Evidence Gap in Obesity Prevention: A Framework to Inform Decision Making. Washington, DC: The National Academies Press.

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“Knowing is not enough; we must apply. Willing is not enough; we must do.” — Goethe Advising the Nation. Improving Health.

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The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distin- guished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Charles M. Vest is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of pol- icy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. Charles M. Vest are chair and vice chair, respectively, of the National Research Council. www.national-academies.org

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COMMITTEE ON AN EVIDENCE FRAMEWORK FOR OBESITY PREVENTION DECISION MAKING SHIRIKI K. KUMANYIKA (Chair), Professor of Epidemiology and Associate Dean for Health Promotion and Disease Prevention, University of Pennsylvania School of Medicine, Philadelphia DAVID B. ABRAMS, Director, Schroeder Institute for Tobacco Research and Policy Studies, American Legacy Foundation, Washington, DC; Professor, Department of Health, Behavior and Society, The Johns Hopkins Bloomberg School of Public Health, Baltimore, MD ROSS C. BROWNSON, Professor of Epidemiology, School of Medicine (Siteman Cancer Center) and George Warren Brown School of Social Work, Washington University in Saint Louis, MO FRANK CHALOUPKA, Professor of Economics, Director, UIC Health Policy Center, University of Illinois at Chicago MADHABI CHATTERJI, Associate Professor of Measurement-Evaluation & Education, Teachers College, Columbia University, New York BARBARA A. DENNISON, Director of Policy and Research Translation, Division of Chronic Disease and Injury Prevention, New York State Department of Health, Albany CHRISTINA ECONOMOS, New Balance Chair, Childhood Nutrition, Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA STEVEN GORTMAKER, Professor of Practice of Health Sociology, Department of Society, Human Development, and Health, School of Public Health, Harvard University, Boston, MA LAWRENCE W. GREEN, Professor, Department of Epidemiology and Biostatistics, Helen Diller Family Comprehensive Cancer Center, University of California–San Francisco ROBERT A. HIATT, Professor and Co-Chair of Epidemiology and Biostatistics, Deputy Director, Helen Diller Family Comprehensive Cancer Center, University of California–San Francisco WILLIAM PURCELL, III, Director, Institute of Politics, John F. Kennedy School of Government, Harvard University, Cambridge, MA ROBERT SEGE, Professor of Pediatrics, Boston University School of Medicine, Boston, MA HAROLD SOX, Editor Emeritus, Annals of Internal Medicine, American College of Physicians of Internal Medicine, Philadelphia, PA ADOLFO M. VALADEZ, Assistant Commissioner, Division of Prevention and Preparedness Services, Texas Department of State Health Services, Austin LETICIA VAN DE PUTTE, Senator, Texas State Senate, San Antonio STEPHEN G. WEST, Professor of Quantitative and Social Psychology, Department of Psychology, Arizona State University, Tempe v

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Study Staff LYNN PARKER, Scholar LESLIE J. SIM, Program Officer EMILY ANN MILLER, Research Associate SAUNDRA LEE, Senior Program Assistant MATTHEW SPEAR, Senior Program Assistant ANTON BANDY, Financial Officer GERALDINE KENNEDO, Administrative Assistant LINDA D. MEYERS, Food and Nutrition Board Director vi

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Reviewers T his report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this inde- pendent review is to provide candid and critical comments that will assist the institu- tion in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report: JOHN P. ALLEGRANTE, Professor and Chair, Department of Health and Behavior Studies, Columbia University, New York ALICE S. AMMERMAN, Director, Center for Health Promotion and Disease Prevention, University of North Carolina at Chapel Hill LISBETH BAMBERGER SCHORR, Director, Project on Effective Interventions, Harvard University, Washington, DC KELLY D. BROWNELL, Director, Rudd Center for Food Policy and Obesity, Yale University, New Haven, CT LINDA COLLINS, Director, The Methodology Center, Pennsylvania State University, State College DAVID CORDRAY, Professor, Department of Psychology and Human Development, Vanderbilt University, Nashville, TN TRISHA GREENHALGH, Professor, Primary Care and Population Sciences, University College London, UK ABBY KING, Division Chief, Stanford Prevention Research Center, Stanford University School of Medicine, Stanford, CA LISA M. KLESGES, Professor and Director, School of Public Health, University of Memphis vii

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ALFREDO MORABIA, Professor of Clinical Epidemiology, Mailman School of Public Health, Columbia University, New York LYNN SILVER, Assistant Commissioner, Chronic Disease Prevention & Control, New York City Department of Health & Mental Hygiene JUNE STEVENS, Chair, Department of Nutrition, University of North Carolina School of Public Health, Chapel Hill MAY C. WANG, Associate Professor, Department of Community Health Sciences, University of California–Los Angeles School of Public Health, Los Angeles Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommenda- tions nor did they see the final draft of the report before its release. The review of this report was overseen by ENRIQUETA C. BOND, President Emeritus, Burroughs Wellcome Fund and CUTBERTO GARZA, Provost and Dean of Faculties, Boston College. Appointed by the National Research Council and the Institute of Medicine, they were responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution. Reviewers viii

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Preface T he impetus for this study was a recognition on the part of the study’s sponsors, the Institute of Medicine (IOM), and ultimately the scholars who served as com- mittee members of the need to better align the evidence base for obesity prevention with the evidence needs of policy makers and professionals who are making decisions in this arena. Addressing the nation’s obesity epidemic requires well-reasoned actions to transform the current obesity-promoting landscape such that the average adult or child is likely to avoid excess weight gain. Relevant actions are being considered and taken by decision makers in international, national, state, and local governments and by organizations and agencies in the profit and nonprofit sectors on the basis of the evidence at hand, as well as other considerations. Many of these actions involve changes in physical environments, public policies, or organizational practices. Some proposed actions will be questioned on the basis of feasibility or effectiveness; some will be strongly opposed by those who stand to lose economically or in other respects. Decision makers can use evidence to assess the potential impacts, advantages, and dis- advantages of particular actions; respond to concerns; and argue their case. The sponsors of this report have essentially called on the scientific community to rise to the challenge and transform the evidence picture to be commensurate with the needs. Limitations in the current evidence base are manifest in scientific review articles that identify a paucity of obesity prevention interventions found to be effec- tive; in study designs that fail to address the complexity of the obesity problem when viewed from a population perspective; in the lack of data with which to cost out and prioritize various strategies; and in evidence of major policy decisions that—however justified from a practical perspective—are being taken in the absence of evidence that might be helpful and perhaps critical in determining which actions should be contin- ued, replicated, or scaled up. If “evidence” is given the usual interpretation of research evidence, the impli- cation is that the research community—those expected to be the keepers, judges, and providers of evidence—need to do something different so the research will have ix

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more practical utility. Several questions then arise: What is that “something differ- ent”? What is missing from the evidence that is available now? How can and should identified gaps be filled? And ultimately, can a more useful approach to evidence be described in a way that (1) engenders agreement and respect within the scientific com- munity, (2) has practical utility, and (3) therefore, also reassures decision makers of the validity of the approach and motivates its use? These are the fundamental issues addressed in this report, and the committee has wrestled long and hard to achieve a result that will indeed transform the way obesity prevention research is defined and undertaken to better meet potential user needs. The committee deliberated extensively about what actually constitutes good research with respect to complex population problems such as obesity, and when and how currently held assumptions about research quality require rethinking to make research results usable in the real world. We considered how concepts of evidence can be broadened to encompass information that is sound but not necessarily what comes to mind when one thinks of evidence in traditional terms. We examined why the prob- lems we identified with the evidence framework for obesity prevention exist and what might stand in the way of implementing a new framework. We did not find shortcuts. From a practical perspective, aligning evidence with user needs and filling evidence gaps will require dedicated effort, time, money, and infrastructure, as outlined in this report’s recommendations—inputs that will have broader relevance and utility when also applied to other population health problems. We did identify new approaches, some reflected in efforts already under way and others that could be implemented immediately. These new approaches include talking and sharing across disciplines; thinking about relevance and the connections among the myriad population- and community-level influences that can be focal points of obesity prevention initiatives; and taking advantage of the opportunity to evaluate ongoing initiatives, that is, to obtain the practice-based evidence that is intrinsically relevant to natural settings. The committee was a truly tireless group with a shared commitment to bringing the full potential of scientific excellence, broadly defined, to bear on addressing popu- lationwide obesity, including the application of learning from exemplary efforts of this type in other areas of population health. The committee was aided by a stellar roster of colleagues who gave us the benefit of their thinking and experience at two public workshops: Stephanie Coursey Bailey, Allan Best, Steven Daniels, Ana Diez-Roux, Joseph Hagan, Jr., Jack Homer, Susan Jebb, David L. Katz, Bobby Milstein, J. Michael Oakes, Joshua Sharfstein, Lynn Silver, and June Stevens. As the person given the privi- lege of chairing this effort, I express my sincerest gratitude to all of these colleagues, as well as to the study’s sponsors—Kaiser Permanente, the Robert Wood Johnson Foundation, and the Centers for Disease Control and Prevention—for the vision that was inherent in the committee’s statement of task. In addition, and on behalf of the committee as a whole, I commend and thank our very capable IOM staff who applied their patience, wisdom, and hands-on assistance liberally and expertly throughout the course of this effort: Lynn Parker, Study Director; Leslie Sim, Program Officer; Emily Preface x

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Ann Miller, Research Associate; Matthew Spear and Saundra Lee, Senior Program Assistants; and Linda D. Meyers, Food and Nutrition Board Director. The results of the committee’s efforts are offered to decision makers and to the research community for use, scrutiny, and debate, recognizing that any effort of this type will be a work in progress that will benefit from interactions with the people and contexts to whom and to which it is relevant. In keeping with the spirit of this report, the debate should be far from “academic,” deriving its energy and arguments by remaining close to the action in the field. Shiriki K. Kumanyika, Chair Committee on an Evidence Framework for Obesity Prevention Decision Making xi Preface

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Contents SUMMARY 1 SECTION I: CONTEXT 1 Introduction 17 2 Obesity Prevention Strategies in Concept and Practice 35 3 Rationale for and Overview of the L.E.A.D. Framework 55 SECTION II: THE FRAMEWORK 4 Defining the Problem: The Importance of Taking a Systems Perspective 71 5 Specifying Questions and Locating Evidence: An Expanded View 89 6 Evaluating Evidence 115 7 Assembling Evidence and Informing Decisions 133 8 Opportunities to Generate Evidence 159 SECTION III: NEXT STEPS 9 Next Steps 187 10 Conclusions and Recommendations 197 APPENDIXES A Acronyms and Glossary 207 B Other Evidence Projects 223 C Review of Existing Reviews on Obesity Prevention 227 D Information Sources for Locating Evidence 269 E An In-Depth Look at Study Designs and Methodologies 277 F Agendas from Two Workshops 301 G Committee Member Biographical Sketches 305 INDEX 313 xiii

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