Summary

Institute of Medicine Regional Symposium

Progress in Preventing Childhood Obesity: Focus on Communities

In collaboration with the Healthcare Georgia Foundation Supported by The Robert Wood Johnson Foundation

October 6–7, 2005

Georgia Tech Hotel and Conference Center

Atlanta, Georgia

The nation faces a growing epidemic of childhood obesity that threatens the immediate health of our children and their prospects of growing up healthy into adulthood. During the past 30 years, obesity in the United States has more than doubled among young children aged 2–5 years and adolescents aged 12–19 years, and it has more than tripled among youth aged 6–11 years. Currently, more than 9 million children 6 years of age and older are considered to be obese. The sequelae of obesity among children and youth are also rapidly increasing, including an increased risk of type 2 diabetes, hypertension, metabolic syndrome, asthma, and social and psychological consequences including low self-esteem and depression.

The changes needed to reverse the obesity trend must be robust enough to counteract the factors that led to obesity in the first place. Effective change requires a population-based prevention approach and a sustained, comprehensive response throughout the nation. At the individual level, this entails attaining energy balance that equalizes food or energy consumption with energy expenditure through physical activity to achieve a healthy weight. Yet this issue is not the responsibility of individuals alone, especially for children who have little or no control over the social and environmental factors with which they must live. The nation shares a collective responsibility in rectifying the childhood obesity trend, and a clear focus of prevention efforts should involve the communities that affect the daily lives of our children and youth. Moreover, a special focus must be placed on low-income, high-risk communities where obesity rates are highest due to factors such as lack



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Progress in Preventing Childhood Obesity: Focus on Communities - Brief Summary: Institute of Medicine Regional Symposium Summary Institute of Medicine Regional Symposium Progress in Preventing Childhood Obesity: Focus on Communities In collaboration with the Healthcare Georgia Foundation Supported by The Robert Wood Johnson Foundation October 6–7, 2005 Georgia Tech Hotel and Conference Center Atlanta, Georgia The nation faces a growing epidemic of childhood obesity that threatens the immediate health of our children and their prospects of growing up healthy into adulthood. During the past 30 years, obesity in the United States has more than doubled among young children aged 2–5 years and adolescents aged 12–19 years, and it has more than tripled among youth aged 6–11 years. Currently, more than 9 million children 6 years of age and older are considered to be obese. The sequelae of obesity among children and youth are also rapidly increasing, including an increased risk of type 2 diabetes, hypertension, metabolic syndrome, asthma, and social and psychological consequences including low self-esteem and depression. The changes needed to reverse the obesity trend must be robust enough to counteract the factors that led to obesity in the first place. Effective change requires a population-based prevention approach and a sustained, comprehensive response throughout the nation. At the individual level, this entails attaining energy balance that equalizes food or energy consumption with energy expenditure through physical activity to achieve a healthy weight. Yet this issue is not the responsibility of individuals alone, especially for children who have little or no control over the social and environmental factors with which they must live. The nation shares a collective responsibility in rectifying the childhood obesity trend, and a clear focus of prevention efforts should involve the communities that affect the daily lives of our children and youth. Moreover, a special focus must be placed on low-income, high-risk communities where obesity rates are highest due to factors such as lack

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Progress in Preventing Childhood Obesity: Focus on Communities - Brief Summary: Institute of Medicine Regional Symposium of access to healthful foods, a paucity of safe or available venues for physical activity, and a lack of education about proper nutrition and the benefits of physical activity. Minority children and youth are at greatest risk for obesity, especially African Americans, Hispanics, American Indians, and Asians/Pacific Islanders living in low-income communities throughout the nation. In 2002, Congress charged the Institute of Medicine (IOM) with developing a prevention-focused action plan to reduce the number of obese children and youth in the United States. After analyzing the behavioral, social, cultural, and other environmental factors involved in childhood obesity and promising approaches for prevention efforts, the IOM released the report, Preventing Childhood Obesity: Health in the Balance (IOM, 2005), which identified promising approaches for obesity prevention efforts and put forth a set of recommendations for a variety of stakeholders and sectors to implement obesity prevention strategies for government, industry, communities, schools, and home. The IOM committee developed its recommendations based on the best available evidence at the time by integrating information from the obesity prevention literature, dietary and physical activity literature, and parallel evidence from other public health issues with an emphasis on and commitment to evaluate promising obesity prevention interventions. In 2005, with support from the Robert Wood Johnson Foundation (RWJF), the IOM is building on its previous work by initiating a study to assess progress in childhood obesity prevention efforts. The IOM, through its Food and Nutrition Board, has appointed a 13-member multidisciplinary committee with expertise in child health, obesity, nutrition, physical activity, food industry, community-based evaluation, public health, and public policy to conduct the study. In 2005, the committee organized three regional symposia in the midwest, southeastern, and western United States to galvanize obesity prevention efforts of local, state, and national decision-makers, community and school leaders, grassroots organizations, and industry—including the food, beverage, restaurant, leisure, and entertainment industries. These three symposia involved disseminating the findings and recommendations of the original IOM report; catalyzing dialogues that highlight promising practices for schools, communities, and industry; and identifying assets and barriers to move forward with obesity prevention efforts in these sectors and selected regions. In collaboration with the Healthcare Georgia Foundation, the committee held its second regional symposium in Atlanta, Georgia on

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Progress in Preventing Childhood Obesity: Focus on Communities - Brief Summary: Institute of Medicine Regional Symposium October 6–7, 2005. Recognizing that the health of children and youth is closely linked to the health of communities, this symposium focused on the specific IOM report recommendations for stakeholders at the local, state, regional, and federal levels to explore how to create healthy communities for U.S. children and youth (Box 1). The symposium included three plenary panels that focused on mobilizing neighborhood and community grassroots efforts; mobilizing city, county, and state efforts; and exploring additional steps that can be taken by stakeholders to overcome barriers to further progress. Three break-out sessions focused on changing the environment, fostering collaboration between the public health and health care communities, and supporting and evaluating community efforts to prevent childhood obesity. A program agenda is at the end of this summary. The symposium provided a useful forum for stakeholders to explore viable strategies and exchange information about promising practices and approaches for addressing barriers to obesity prevention initiatives. This brief summary highlights the recurring themes that emerged from the symposium for accelerating change and moving forward with obesity prevention efforts: empower communities and neighborhoods, change the environment, forge strategic partnerships, garner and mobilize political support, educate stakeholders, identify leaders and build on cultural assets, collect and disseminate local data, evaluate programs and interventions, and translate successful interventions to other communities. Approximately 90 individuals active in childhood obesity prevention efforts in the southeastern region of the United States who represented a range of stakeholder perspectives and innovative practices in local communities—including students, community leaders, physicians, health educators, clergy, teachers, and state and federal government officials—were invited to participate in the symposium. The contents of this summary reflect specific examples presented and discussed during the symposium, and unless otherwise noted, the general perspectives of the participants. This summary, along with two other symposia summaries, and a more detailed discussion of insights and regional examples, will be incorporated in the IOM committee’s final report on progress in preventing childhood obesity that will be released in the fall of 2006.

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Progress in Preventing Childhood Obesity: Focus on Communities - Brief Summary: Institute of Medicine Regional Symposium Empower Communities and Neighborhoods Communities are social entities that are either defined as groups of people who live within certain geographic boundaries or who share certain relational characteristics such as a common purpose, interests, culture, racial/ethnic background, religion, or occupation. Very generally, all communities have a shared sense of place, belonging, and identity. This collective sense of identity represents an important resource for fostering change among members of a community, and for designing or adapting interventions to improve a community. A strong sense of common identity and purpose can support community-based efforts, which are as essential to foster community change as are top-down strategies. To help empower neighborhoods and communities, one speaker at the symposium presented his perspective that the nation needs to incorporate the many root causes of obesity—including poverty, disparities, low-quality housing, unemployment, and issues of access—into its discussions about this complex problem. As was shown during the Civil Rights movement in the 1960s, a nonviolent movement in which people unite together to strive for change can indeed be a powerful force to create change. He suggested that a key factor needed to mobilize communities around healthy lifestyles through community-based interventions is civic engagement, whereby community citizens become activated and work toward change. Children and youth are an integral part of this movement; if taught to be concerned about health disparities within their communities, they can become a major influence in promoting more equitable health access for their communities and future generations. A panel of speakers at the symposium discussed issues relevant to increasing awareness and mobilizing the faith-based communities around childhood obesity prevention. A large proportion of Americans state that religion is important in their lives and may profoundly influence their world views, including African Americans and Hispanics—two U.S. ethnic populations that are at high risk for obesity. For this reason, many faith-based communities are currently adopting the challenge of obesity prevention within their places of worship by identifying factors either contributing to or deterring health promotion and childhood obesity prevention efforts in these communities. Efforts underway described by the panelists involve ministers conveying health tips to congregations and using scriptural principles that underscore a healthy lifestyle during

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Progress in Preventing Childhood Obesity: Focus on Communities - Brief Summary: Institute of Medicine Regional Symposium church services, disseminating materials that present information on nutrition and physical activity, hosting health fairs, training volunteers to be health promoters within their congregations, establishing wellness ministries, holding regular meetings where people from various faith communities can explore matters pertinent to their lives, providing more nutritious Sunday school snacks and church meals, and engaging children in physical activity before church school. Potential barriers identified by the panelists include a lack of pastoral commitment to health promotion and obesity prevention activities, lack of sufficient resources, limited participation of the congregation, difficulty in changing church traditions, and the unwillingness of ministers to work across denominations. Several presenters emphasized that as communities become empowered, an adequate infrastructure must exist to capture the energy and enthusiasm of individuals who are activated. It was also suggested by presenters that bold, practical, communal, yet inexpensive approaches must be included in an intervention strategy to sustain their energy and commitment. Examples include building food security and community cohesion through community gardens or efforts to involve the community in traveling to work or school by walking or biking instead of a motorized vehicle. Fostering and sustaining the participation of individuals and communities most affected by obesity is vital to build strong coalitions that can effectively address the problem in the long-term. Change the Physical Environment Individual choice has increasingly been framed as a matter separate from its sociocultural and economic contexts. However, context and environment affect the personal choices that individuals make on a daily basis. Several speakers noted that many low-income communities in the United States are unintentionally developed such that there is greater availability of and access to high-calorie and low-nutrient foods and beverages and limited access to opportunities for regular physical activity. If fresh produce is not available or affordable, most families and their children may choose less nutritious snacks from the food environment, such as the neighborhood convenience store on the way home from school. If communities are developed without sidewalks or bike paths, a child may need to be driven or ride the bus to school rather

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Progress in Preventing Childhood Obesity: Focus on Communities - Brief Summary: Institute of Medicine Regional Symposium than walk or ride a bike. If safe places to play and be physically active are not available, children and youth have few options apart from television and other sedentary pursuits. By taking an ecological approach to changing the physical environment (e.g., recognizing the interconnectedness of biological, behavioral, physical, and socioeconomic domains), communities can be developed in a way that supports children and youth to achieve a healthy weight. For example, by adding play space to neighborhoods, parks, and programs, or by encouraging corner convenience stores to stock healthier food and beverage options, children, youth, and their families may begin to utilize these services and purchase these products. Different types of interventions are used at the neighborhood, city, and state levels to provide venues for facilitating physical activity within communities. The first type changes the rules by which new communities are developed (e.g., zoning and subdivision ordinances), while the second type changes the physical environment in existing communities (e.g., sidewalk construction, new parks and playgrounds). It is possible to structure neighborhoods so they facilitate physical activity by how they are redeveloped (via sidewalks, bikeways, trails, parks) to promote safety and nurture a sense of community. For example, one effort succeeded in building more than 90 miles of a connected trail system for pedestrians throughout metropolitan Atlanta. Certain types of community development are conducive with the principle of environmental justice—that every neighborhood or community should have the same degree of protection from environmental and health hazards and participate in developing public policies that create and shape the healthy environments in which people live, learn, and work. One environmental justice effort in the Bronx succeeded in raising more than $30 million to create a greenway along the waterfront to attract pedestrians. Several presenters emphasized the principle that all people should have the right to access healthful and nutritious foods. Several public health interventions at the regional level are providing incentives for new supermarkets to be built in low-income neighborhoods to make it easier for families to have access to affordable fresh fruits and vegetables. A national coalition of more than 300 anti-hunger, sustainable agriculture, environmental, and social justice organizations strives to promote community food security—to ensue that all people have access to affordable, nutritious, and culturally appropriate food at all times. The coalition seeks to develop self-reliance among all communities in

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Progress in Preventing Childhood Obesity: Focus on Communities - Brief Summary: Institute of Medicine Regional Symposium obtaining their food locally or regionally by supporting local farmers through farmers’ markets, community supported agriculture, and community gardens. One strategy entails schools buying fresh produce from local farmers to be used for snacks and school lunches, whereas another strategy has made it easier for low-income people to use their electronic benefit transfer cards at local farmer’s markets. Bringing grocery stores and farmers’ markets to low-income areas does more than enable access to healthful foods. It also serves to economically revitalize local communities by providing jobs and enhancing the value of an area with the amenities provided. In New York City, Harlem is a neighborhood in the borough of Manhattan that experiences disproportionate levels of violence and poverty. One speaker described how a fitness and nutrition center was created that engages young people in proactive health initiatives that nurture social responsibility, promote investment in the community, and help to prevent obesity. The center provides adolescents with a safe space to enhance well-being, informs them about risks that impact their health and the health of their families, demonstrates the importance of physical activity and nutrition in maintaining wellness and preventing disease, involves them in developing public health strategies, and promotes academic excellence. The center recently undertook a project where it reclaimed an abandoned city-owned lot and transformed it into a community garden. To demonstrate their mission of social responsibility, the youth tending the garden donate hundreds of pounds of the food harvested annually to a local kitchen that serves homeless and hungry people within their community. A key element of the intervention—intergenerational role modeling and storytelling in accordance with African-American tradition—reinforced positive ethnic identity and self-efficacy. One adolescent involved in many of the center’s activities commented that his experience at the center had empowered him by encouraging him to be transformed from a follower into a leader. This underscores the necessity of attending to the sociocultural environment to complement physical environmental interventions in underserved communities with many competing demands, priorities, and needs. Forge Strategic Partnerships Forging strategic partnerships emerged as common theme for promoting success of many interventions presented at the symposium.

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Progress in Preventing Childhood Obesity: Focus on Communities - Brief Summary: Institute of Medicine Regional Symposium Partnerships need to involve multiple sectors—local businesses, local and state government support, community-based organizations, and industry support—to leverage the strength needed to precipitate change. Partnerships are useful in that they provide a network of support, bring increased credibility to each partner, use limited resources for mutual benefit, and create networking advantages through shared communication channels. A statewide school-based nutrition and physical activity intervention in Mississippi found that the initial development of a health advisory council representing different stakeholder perspectives at each school greatly facilitated the negotiations, agreement, and implementation of the program. In addition, the partners in the intervention have served as a sounding board for suggestions regarding program implementation. Seeking out and gaining the trust of those who might not support a given intervention can also greatly facilitate a movement. For example, several people noted that they attained success in achieving their healthy vending machine initiatives by bringing the vendors to the discussion table along with nutritionists. Partnerships may also enable programs to overcome funding shortages by utilizing internal resources as opposed to relying on grants. For example, one speaker described a partnership consisting of youth organizations, the American Heart Association, a local grocery store chain, and others that focused on initiating after-school programs in Florida. They formed an alliance with the student nursing program at the University of Central Florida to assist in evaluation efforts for the program. Accordingly, partnerships may also provide technical assistance to groups or organizations that otherwise lack scientific, statistical, or evaluation expertise. There is great potential for promoting partnerships through coalition building that involves faith-based communities. Faith-based groups that engage with local youth-related organizations may provide a unique avenue for reaching subgroups of children and their parents in communities to promote a healthy lifestyle. The intersection of faith-based communities with local and national government agencies tends to be a sensitive area, but there are many opportunities to explore joint efforts. One faith-based organization is assembling a report for government agencies on how to work effectively with African-American churches.

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Progress in Preventing Childhood Obesity: Focus on Communities - Brief Summary: Institute of Medicine Regional Symposium Garner and Mobilize Political Support The intersection between public policy and public health can be a dramatic influence to change societal norms. Attaining the support of governmental leaders for initiatives related to obesity prevention can generate considerable momentum to institute interventions and initiate change. Approaches to work effectively with political entities entail establishing credibility for individuals and their organizations as advocates for change, building a statewide support network with local capacity, influencing key opinion leaders who develop policy and allocate resources, gaining insight into the distribution of power and formal and informal policy-making processes, and acquiring familiarity with political issues and laws to speak in an informed manner about change (e.g., understanding land use laws when advocating for new sidewalks within neighborhoods). All of these factors contribute to the important need to promote civic engagement that can mobilize political support. Mobilizing government efforts for obesity prevention within a given state helps to create a wide-reaching infrastructure of support. Sustainability is more likely to be achieved when a comprehensive plan rallies state residents behind an issue because people’s expectations, and their cultural perspectives and societal norms, may begin to change. The West Virginia Healthy Lifestyle Coalition was established as an obesity prevention initiative after assessing the health and economic burden that obesity was creating throughout the state. The mission of the Coalition is to coordinate and promote healthy lifestyle programs through surveillance, education, community-based intervention and outcomes research as well as legislative and public policy. Specifically, the group provides policy recommendations to the governor and legislators related to increasing physical activity, fruit and vegetable consumption, and the proportion of West Virginians who are at a healthy weight. Recent legislative efforts in the state have focused on mandating increased physical activity in schools, limiting the types of beverages sold in schools, performing regular measurements of students’ body mass indexes (BMIs) to evaluate progress, providing incentives for worksite wellness, and creating a governor’s office-led coalition that helps to make policy decisions for the state. The state is currently working on initiatives that will require full-service and quick-serve restaurants to provide nutritional information to the public about the foods, beverages,

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Progress in Preventing Childhood Obesity: Focus on Communities - Brief Summary: Institute of Medicine Regional Symposium and meals served; explore the use of selectively taxing less healthful foods; encouraging the use of food stamps to purchase more healthful foods and beverages; and promoting breastfeeding among new mothers. Likewise, another statewide initiative called Eat Smart, Move More…North Carolina promotes opportunities for healthful eating and physical activity. The state builds capacity at the community level by funding regional and county programs based on the view that people are more likely to work toward objectives that they helped to create. Various sectors (e.g., civic groups, schools, faith-based groups) have the latitude to adopt the strategies they deem appropriate for promoting a healthy lifestyle, and the state then awards the organizations certification for the programs provided that the interventions pass a set of standards mandated by the state. The North Carolina initiative also provides funding and incentives for developers to alter the built environment to expand opportunities for physical activity. Under this initiative, more than 41 miles of new walking and biking trails have been created throughout the state. In 1999, the Louisiana Council on Obesity Prevention was created to administer and coordinate obesity initiatives in the state and between the state and the federal government by developing a comprehensive approach to obesity prevention and the management of obesity-related conditions. The Council advises the state health department with regard to organizing efforts to achieve programmatic objectives, disseminating expert opinions and developing policies, and creating awareness among various state sectors. The Council has assisted in passing several state laws including requiring 30 minutes of physical activity per day in elementary schools, allowing only healthy food choices in elementary and middle school vending machines, and mandating that at least 50 percent of the vending machine choices in high schools are healthy options. The Council and state worked directly with the food service industry to get these latter two laws passed. In addition to adopting many of the policies found in other states, The Georgia Physical Activity Network (GPAN) advocates for physical activity and nutrition within the state of Georgia that disseminates information to residents that encourages them to act politically in the obesity prevention effort. For example, the network encourages Georgians to inform legislators about their health-related concerns, such as ensuring that physical education is offered in schools throughout the state, and it asks residents to be politically active by voting on measures

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Progress in Preventing Childhood Obesity: Focus on Communities - Brief Summary: Institute of Medicine Regional Symposium that support new and existing local and state initiatives promoting physical activity and healthful eating. As some of the examples discussed indicate, change is more easily achieved when a plan for such change exists, to create a framework and map out how the change will take place in communities. A county commissioner from Georgia recommended that all communities create a comprehensive plan for land use development that extends 20 years into the fixture. This might include requiring that all future neighborhoods be built with sidewalks, that a residential area of a given size must have a green space or park, and other such design issues related to public health. Federal, state, and local governments can be major change agents to facilitate obesity prevention efforts. The federal government can serve as a source of guidance and provide recommendations based on evidence about promising practices, and it has the power to institute national policies. For example, the Centers for Disease Control and Prevention (CDC) can work with state partners, particularly in providing technical assistance to evaluate efforts. Federal strategies are needed to weave the many obesity prevention programs together and bolster the public health infrastructure to strengthen obesity prevention efforts. Educate Stakeholders At-risk communities are often very concerned about and eager to secure changes that promote the health of community members; the key is providing them with the information they need to be effective. Preventing childhood obesity requires the ongoing interactions among children, families, communities, and state and government officials. With many issues to be concerned about, many individuals may fail to recognize a problem unless they are directly informed about the matter. For instance, people may make the connection with issues surrounding hunger and food insecurity, but proper nutrition may be overlooked. Efforts must be made to inform people about the root causes of obesity and the lifestyle changes needed to reverse the trend. Stakeholders at various levels (e.g., children, parents, families, racial/ethnic and cultural groups) should be targeted for ongoing education about the risks of obesity, the value of a healthy lifestyle, the options available to them, and the health disparities that exist among different demographic groups. Education on nutrition and healthy lifestyles is enhanced by making the learning experience fun and engaging. The Mississippi Extension

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Progress in Preventing Childhood Obesity: Focus on Communities - Brief Summary: Institute of Medicine Regional Symposium task force of community leaders and set in motion several messages and programs throughout the county to help address obesity. Several assessment tools exist for collecting health, nutrition, physical activity, and obesity prevalence data in schools. The CDC has developed the School Health Index Self-Assessment & Planning Guide in partnership with school administrators and staff, school health experts, parents, and national nongovernment health and education agencies. Schools can use this guide to identify strengths and weaknesses of their policies and programs, develop an action plan, and engage teachers, parents, students, and the community in promoting health-enhancing behaviors that improve health. The FitnessGram is a tool that allows physical education teachers to collaborate with schools to collect information about BMI, percent body fat, aerobic fitness, muscle strength, endurance, and flexibility to assess the health of students. Using a positive approach, children are categorized in terms of being “in the healthy fitness zone” or “needing improvement.” These data are now being used as surveillance measures, and to further the utility of the data, efforts are being made to develop a system where the data can be imported into district-level or state-level databases. State-level data are particularly powerful at driving policy change. The CDC established the Behavioral Risk Factor Surveillance System (BRFSS) in 1984, which uses standard core questionnaires via telephone surveys to track health risks, including obesity, among U.S. adults. At the time of its inception, 15 states participated in monthly data collection; by 1994, all states, the District of Columbia, and three territories were participating in the BRFSS. The collected data may not only be compared across states, but some states have stratified their samples to allow the data to be analyzed by region within their respective states. Similar to the BRFSS, the smaller Youth Risk Behavioral Surveillance System (YRBSS) is a population-based measure tracking tobacco use, drug use, physical activity, fruit and vegetable consumption, and the BMI of high school youth and selected middle-school youth over time. Although national, state, and local survey data have been collected since 1991 and the system provides comparable data among different groups of children and youth with different levels of health risks, there are gaps in data collection for younger children.

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Progress in Preventing Childhood Obesity: Focus on Communities - Brief Summary: Institute of Medicine Regional Symposium Evaluate Programs and Interventions Community initiatives addressing obesity among the nation’s children and youth share the common goal of creating environments that reduce the obesity risk and promoting healthy behaviors. For that reason, it is important to document new programs, policies, and practices that help to advance knowledge and information exchange for obesity prevention over time. Insufficient evidence about an intervention is not the same as evidence that an intervention does not work. Otherwise promising interventions for which the evidence is insufficient should be more thoroughly researched. Interventions that produce no effect, or that may have unintended consequences, should be replaced with more effective interventions. Monitoring and tracking changes within communities following the implementation of obesity prevention interventions is imperative for assessing the success of such strategies. Positive change needs to be publicly promoted and rewarded. Taking pride in incremental successes is important for sustaining long-term goals, especially given the complexity of childhood obesity prevention, and the importance of cumulative effects of multiple interventions to obtain measurable results. As recommended by the Work Group on Health Promotion and Community Development at the University of Kansas, key questions to ask during a community evaluation process include: Is the intervention catalyzing community change to prevent childhood obesity? What factors or processes are associated with the rate of community change for preventing childhood obesity? How are community changes contributing to the efforts to promote health? Are community changes associated with improvements in population-level outcomes related to childhood obesity? Designing and incorporating an evaluation into the overall strategic plan of a specific intervention from the time of its inception will help to systematically document how the intervention develops under dynamic and diverse contexts. For example, one tri-state intervention evaluated by East Tennessee State University carefully devised a plan to measure the intensity, duration, and frequency of the implemented activities; the change in students’ knowledge about physical activity, nutrition, and

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Progress in Preventing Childhood Obesity: Focus on Communities - Brief Summary: Institute of Medicine Regional Symposium general health via pre-post tests; the amount of accumulated activity during the school day; the extent to which the intervention objectives were met; and the change in children’s BMI over the study period. Evaluations need not follow the strict structure of randomized, controlled trials in order to provide useful information. Evaluations can be designed based on a logic model or program theory framework that explicitly delineates the short-term and long-term goals and outcomes of an intervention. Many communities may lack the expertise or funding to conduct thorough scientific evaluations. In these instances, inviting university collaboration to help evaluate an intervention may provide a viable option. The Work Group on Health Promotion and Community Development at the University of Kansas has created a community toolbox that includes practical guidance for implementing community health interventions. These guidelines include a section on evaluation. The federal government has also designed various surveillance systems to help cities and states collect obesity data that can be used to gauge intervention efficacy at a larger level, such as the CDC’s BRFSS and YRBSS. Moreover, the CDC provides technical assistance at the state and local levels on how to collect and analyze evaluation data. In addition to evaluating implemented initiatives to track progress in obesity for individuals, other levels of research are required as well. Data for large-scale, evidence-based public policy would be useful to assess whether states or governments are effectively investing in the range of resources needed and used. Similarly, community-based participatory action research at the population level and consumer behavior research represent other areas where additional information is needed to inform interventions. Evaluating the success of collaborations and partnerships and the sustainability of changes achieved by an intervention may also lend insight into winning strategies. Translate Successful Interventions to Other Communities To disseminate information about best practices and implement these strategies elsewhere, individual interventions should identify what portions of their programs are exportable to other communities. By enabling others to understand documented changes, promising intervention elements can be adapted for another community, as all interventions must be specific for the groups that are being targeted in order to achieve relevance. For example, obesity prevention public

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Progress in Preventing Childhood Obesity: Focus on Communities - Brief Summary: Institute of Medicine Regional Symposium education efforts and media campaigns need to be developed and tailored to target different racial/ethnic and specific demographic groups. No two community interventions are identical, but by building upon other successful interventions and carefully combining information about related interventions, it may help to represent the context and lead to more successful interventions. To address this need, The West Virginia Healthy Lifestyle Coalition created a toolkit for its communities regarding how to implement obesity prevention initiatives and established a website that features a searchable directory of programs. Likewise, a successful intervention that has created a statewide partnership throughout Florida is planning to create a toolkit for other communities to serve as a guide for implementing the program. Toolkits will include the curricula designed for children and parents such as pre-post tests, evaluations, meal plans, giveaway suggestions, various education brochures/handouts, partnership recommendations, and population/community targets. Using another tactic, the Louisiana Council on Obesity Prevention plans to use many of the successful program elements from its statewide second-hand smoke campaign and adapt them for a statewide obesity prevention campaign. Concluding Comments The epidemic of childhood obesity in the United States has the potential to reverse the considerable progress that had been made in the health of the nation’s children and youth over the past several decades. The issue is much more complex than it appears. Although low-income and racial/ethnic minority populations have the highest rates, the surge in childhood obesity encompasses all economic and racial/ethnic groups and all geographic areas within the United States. It is a complicated multifactorial problem involving our food supply and distribution system; restrictions and opportunities for regular physical activity; public policies, individual and collective choices; and interactions among families, schools, communities, businesses, and worksites; and all levels of government—federal, state, and local. A concurrent and collaborative involvement of multiple sectors and stakeholders at all societal levels is required to change the collective societal norms that have contributed to the childhood obesity epidemic. As with laws instituting the mandatory use of seatbelts or that promote tobacco control and smoking prevention, our nation has the power to change societal norms in order to prevent

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Progress in Preventing Childhood Obesity: Focus on Communities - Brief Summary: Institute of Medicine Regional Symposium childhood obesity. Although there is a long road ahead of the nation to effectively address the growing childhood obesity rates, building healthy communities is an essential leverage point, as the health of each individual is closely linked to the health of the community.

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Progress in Preventing Childhood Obesity: Focus on Communities - Brief Summary: Institute of Medicine Regional Symposium Program Agenda Institute of Medicine Symposium Progress in Preventing Childhood Obesity: Focus on Communities In collaboration with Healthcare Georgia Foundation Supported by The Robert Wood Johnson Foundation October 6–7, 2005 Georgia Tech Hotel and Conference Center Atlanta, Georgia October 6, 2005 Opening Session Welcome Martha Katz, Healthcare Georgia Foundation Overview of the IOM Report and Goals for the Meeting Jeffrey Koplan, IOM Committee on Progress in Preventing Childhood Obesity Setting the Context for Obesity Prevention in Communities James Marks, The Robert Wood Johnson Foundation Plenary Panel Presentations and Discussion Mobilizing Neighborhood and Community Grassroots Efforts Developing, implementing, and evaluating grassroots changes related to childhood obesity prevention: barriers and opportunities. Moderator: Antronette Yancey, UCLA School of Public Health Plenary Panel Presentations and Panel Discussion Community Initiatives Stewart Watson and Nancy DeVault, Seminole County Healthy Kids Partnership, Florida

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Progress in Preventing Childhood Obesity: Focus on Communities - Brief Summary: Institute of Medicine Regional Symposium Jeff Bachar, Cherokee Diabetes Prevention Program, North Carolina Beverly Howell, Project Delta Hope and Mississippi Partnerships on Childhood Obesity Plenary Panel Presentations and Panel Discussion Faith-Based Initiatives Anthony Evans, National Black Church Initiative Jean Murphy, Health Ministries, Doraville, Georgia Bethann Cottrell, Concerned Black Clergy of Metropolitan Atlanta Steven Cooper, Mid-South Faith-Based Development Center, Mississippi Plenary Panel Presentations and Discussion Mobilizing City, County, and State Efforts Developing, implementing, and evaluating changes related to childhood obesity prevention at the county and state levels: barriers and opportunities. Moderator: Susan Foerster, California Department of Health Services Plenary Panel Presentations and Panel Discussion Helen Matheny and Dan Foster, West Virginia Healthy Lifestyle Coalition Marcus Plescia, Eat Smart, Move More…North Carolina Stewart Gordon, Chair of Louisiana Council on Obesity Prevention Joan Miller, Bexar County Community Health Collaborative, Texas Carol Johnson, Georgia Physical Activity Network Breakout Sessions What are the barriers to change? What is needed to implement and sustain these changes? Breakout Session #1 Changing the Environment to Prevent Childhood Obesity Facilitators: Ken Powell, Georgia Department of Human Resources; John Peters, Procter & Gamble Company Howard Frumkin, Centers for Disease Control and Prevention, Atlanta

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Progress in Preventing Childhood Obesity: Focus on Communities - Brief Summary: Institute of Medicine Regional Symposium Ed McBrayer, PATH Foundation, Atlanta Andy Fisher, Community Food Security Coalition, Venice, California Duane Perry, The Food Trust, Philadelphia Majora Carter, Sustainable South Bronx, New York Breakout #2 Fostering Collaboration between the Public Health and Health Care Communities to Prevent Childhood Obesity Facilitators: Ann Bullock, Health and Medical Division, Eastern Band of Cherokee Indians; Susan Foerster, California Department of Health Services Veda Johnson, Whitefoord Community Program, Atlanta Donna Hardy, Washington Wilkes County/Medical College of Georgia Partnership Luke Beno, Operation Zero, Kaiser Permanente, Atlanta John Batson, Pediatrician, Columbia, South Carolina Breakout #3 Supporting and Evaluating Community Efforts to Prevent Childhood Obesity Facilitators: Marshall Kreuter, Georgia State University, Atlanta; Jennifer Greene, University of Illinois, Urbana-Champaign Steve Fawcett, University of Kansas, Lawrence Laura Kann, Centers for Disease Control and Prevention, Atlanta Greg Welk, FITNESSGRAM Scientific Advisory Board, Ames, Iowa Karen Schetzina, East Tennessee State University, Johnson City Reception Speaker: David Satcher, Morehouse School of Medicine, Atlanta Friday, October 7, 2005 Welcome Jeffrey Koplan, Emory University and Institute of Medicine (IOM) Committee on Progress in Preventing Childhood Obesity

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Progress in Preventing Childhood Obesity: Focus on Communities - Brief Summary: Institute of Medicine Regional Symposium Opportunities and Challenges in Community-Level Obesity Prevention Efforts James Gavin, Emory University School of Medicine, Atlanta Reports from Breakout Groups Rapporteurs: Ken Powell (Break out #1), Ann Bullock (Break Out #3), Jennifer Greene (Break Out #3) Plenary Panel Presentations and Discussion Preventing Childhood Obesity: What More Can Be Done? What are the barriers to further progress? What more can be done at the national state, and local levels? Moderator: Douglas Kamerow, RTI International, Washington, DC State Perspective Daniel Foster, West Virginia Senate Federal Perspective Janet Collins, Centers for Disease Control and Prevention Local Perspective Larry Johnson, DeKalb County Commission, Georgia Youth Perspective Leann Alexander and Chance Holder, Mississippi 4-H Summary and Next Steps Jeffrey Koplan, Emory University and Institute of Medicine (IOM) Committee on Progress in Preventing Childhood Obesity Group Discussion Closing Session

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Progress in Preventing Childhood Obesity: Focus on Communities - Brief Summary: Institute of Medicine Regional Symposium BOX 1 Recommendations for Communities from the Institute of Medicine Community Programs Local governments, public health agencies, schools, and community organizations should collaboratively develop and promote programs that encourage healthful eating behaviors and regular physical activity, particularly for populations at high risk of childhood obesity. Community coalitions should be formed to facilitate and promote cross-cutting programs and community-wide efforts. To implement this recommendation: Private and public efforts to eliminate health disparities should include obesity prevention as one of their primary areas of focus and should support community-based collaborative programs to address social, economic, and environmental barriers that contribute to the increased obesity prevalence among certain populations. Community child- and youth-centered organizations should promote healthful eating behaviors and regular physical activity through new and existing programs that will be sustained over the long term. Community evaluation tools should incorporate measures of the availability of opportunities for physical activity and healthful eating. Communities should improve access to supermarkets, farmers’ markets, and community gardens to expand healthful food options, particularly in low-income and underserved areas. Built Environment Local governments, private developers, and community groups should expand opportunities for physical activity including recreational facilities, parks, playgrounds, sidewalks, bike paths, routes for walking or bicycling to school, and safe streets and neighborhoods, especially for populations at high risk of childhood obesity. To implement this recommendation: Local governments, working with private developers and community groups, should: Revise comprehensive plans, zoning and subdivision ordinances, and other planning practices to increase availability and accessibility of opportunities for physical activity in new developments Prioritize capital improvement projects to increase opportunities for physical activity in existing areas Improve the street, sidewalk, and street-crossing safety of routes to school, develop programs to encourage walking and bicycling to school, and build schools within walking and bicycling distance of the neighborhoods they serve.

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Progress in Preventing Childhood Obesity: Focus on Communities - Brief Summary: Institute of Medicine Regional Symposium Community groups should: Work with local governments to change their planning and capital improvement practices to give higher priority to opportunities for physical activity. The Department of Health and Human Services (DHHS) and the Department of Transportation should: Fund community-based research to examine the impact of changes to the built environment on the levels of physical activity in the relevant communities and populations. Health Care Pediatricians, family physicians, nurses, and other clinicians should engage in the prevention of childhood obesity. Health-care professional organizations, insurers, and accrediting groups should support individual and population-based obesity prevention efforts. To implement this recommendation: Health-care professionals should routinely track body mass index, offer relevant evidence-based counseling and guidance, serve as role models, and provide leadership in their communities for obesity prevention efforts. Professional organizations should disseminate evidence-based clinical guidance and establish programs on obesity prevention. Training programs and certifying entities should require obesity prevention knowledge and skills in their curricula and examinations. Insurers and accrediting organizations should provide incentives for maintaining healthy body weight and include screening and obesity preventive services in routine clinical practice and quality assessment measures. SOURCE: IOM (Institute of Medicine). 2005. Preventing Childhood Obesity: Health in the Balance. Washington, DC: The National Academies Press.