3
Opportunities and Challenges

OBESITY PREVENTION SOLUTIONS

From the available prevalence data on obesity and risk of obesity in children and youth (see Chapter 1), workshop participants agreed that there is enough evidence to prove that the epidemic is real and that society needs to move now from problem-oriented to solution-oriented research, which includes evaluations1 of the interventions. Based on the risk factors already mentioned, a range of interventions in schools, media outlets, community venues, and healthcare facilities could be implemented, some of them jointly, to counterattack the obesity epidemic in Mexico and the United States.

A comparison between Mexican Americans and Mexicans highlights many commonalities; however, as pointed out by Jaime Sepúlveda, obvious differences in culture and social and political systems require careful analysis before recommendations for the United States are applied to Mexico. The U.S. experience and this joint workshop should serve as a springboard for Mexico to engage in a dialogue about strategies for the Mexican population. Sepúlveda concluded that the establishment of a Mexican Obesity Prevention Task Force that makes recommendations to the Mexican Ministries of Health and of Education is needed.

1

Evaluation can be defined as a systematic assessment of the quality and effectiveness of an initiative, program, or policy and its effects, in order to produce information that can be used by those who have an interest in its improvement or effectiveness.



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Joint U.S.–Mexico Workshop on Preventing Obesity in Children and Youth of Mexican Origin: Summary 3 Opportunities and Challenges OBESITY PREVENTION SOLUTIONS From the available prevalence data on obesity and risk of obesity in children and youth (see Chapter 1), workshop participants agreed that there is enough evidence to prove that the epidemic is real and that society needs to move now from problem-oriented to solution-oriented research, which includes evaluations1 of the interventions. Based on the risk factors already mentioned, a range of interventions in schools, media outlets, community venues, and healthcare facilities could be implemented, some of them jointly, to counterattack the obesity epidemic in Mexico and the United States. A comparison between Mexican Americans and Mexicans highlights many commonalities; however, as pointed out by Jaime Sepúlveda, obvious differences in culture and social and political systems require careful analysis before recommendations for the United States are applied to Mexico. The U.S. experience and this joint workshop should serve as a springboard for Mexico to engage in a dialogue about strategies for the Mexican population. Sepúlveda concluded that the establishment of a Mexican Obesity Prevention Task Force that makes recommendations to the Mexican Ministries of Health and of Education is needed. 1 Evaluation can be defined as a systematic assessment of the quality and effectiveness of an initiative, program, or policy and its effects, in order to produce information that can be used by those who have an interest in its improvement or effectiveness.

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Joint U.S.–Mexico Workshop on Preventing Obesity in Children and Youth of Mexican Origin: Summary Workshop participants highlighted the following key issues as ones to consider in developing a framework for joint interventions: Interventions should focus on environmental changes that support individual behavior change (see discussion on the Berkley Media Series Group Report in Appendix B), and the strategy to mitigate the epidemic should be multilevel, multisectorial, and multidisciplinary. Larger populations could be served by paying attention to issues derived from scaling up the programs. Programs should be sustainable for the long term in terms of funding as well as feasibility. Collaboration with media is critical so that consistent information can reach children and youth through diverse venues. Developing appropriate (social and product) marketing campaigns for children and youth should be an integral intervention component. An ongoing scientific and programmatic exchange to share educational materials, research results, and evaluation of the interventions should be established. During working group discussions it became apparent that the main determinants associated with obesity, highlighted in Figure 7 (Chapter 1), are similar in the two countries and are based on the one complex problem of balance between energy expenditure and energy intake. However, political, social, and economic differences do exist between the United States and Mexico, and researchers should consider those differences when sharing and implementing interventions based on each country’s experiences. The following section highlights some of the barriers that might be encountered when implementing interventions. Barriers and Challenges to Implementing Interventions Most obesity prevention interventions present opportunities as well as challenges. The barriers that challenge our ability to combat the obesity epidemic can be divided into two categories: those related to specific interventions and those related to the social and political environment within which each population resides. For example, in the first category, using media to influence behaviors could be an effective intervention strategy to convey important messages; however, the use of media also can be counterproductive if used to promote unhealthy behaviors. Participants related that school- and community-based interventions also present challenges, such as finding additional resources and time dedicated to promoting obesity prevention. Time limitation is also one barrier often mentioned when considering healthcare interventions. With regard to the second category,

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Joint U.S.–Mexico Workshop on Preventing Obesity in Children and Youth of Mexican Origin: Summary Mendoza (see Appendix B) expressed concerns over the lack of human resources and continuity in obesity research in the United States regarding Mexican–American children—leadership is needed urgently in coordinating all areas from interventions implementation to research and educational campaigns. Mendoza cited as an example of this disconnect the overwhelming amount of information in academic literature that rarely are synthesized to reach the local community, particularly disenfranchised communities (e.g., the poor or Hispanic). Also, generating leadership among the Mexican–American community would help increase the inclusion of Mexican Americans in the U.S. government agenda; this lack of leadership and inclusion of Mexican Americans on the agenda impedes progress in the obesity battle. Workshop participants generally agreed that a commitment to leadership needs to be made. During the working groups and plenary discussions, barriers to alleviating the current epidemic that are unique to the social and political context of each country were highlighted and are listed below. Most of them apply to the United States as well as Mexico to some degree although participants discussed most of them in the Mexican context: In Mexico, the public lacks awareness of the obesity problem. Although this might not be the case at the government level, there is still not a sense of urgency among the public. Moreover, the problem is seen as complex and insurmountable. In the United States, the public, including the Mexican–American community, is much more aware of the problem. One limitation to action in the United States is that Mexican Americans are not being included in the government agenda setting and response. There is a lack of public trust in the government, industry, and academia. The number of food- and nutrition-related policies is scarce in Mexico, and those that exist are implemented and enforced inadequately. There is a lack of organizations that represent consumers; community empowerment and advocacy in Mexico are not common. In Mexico, there is an insufficient number of legislators who can translate and incorporate science into the legislative process and as a result government activities have centered on publishing findings instead of taking legislative actions. Nutritional transitions occurring at different times in the United States and Mexico might be related to differences in both nutritional problems and in socioeconomic distribution and to its relationship with obesity. For instance, in Mexico, stunting and micronutrient deficiencies continue to be of concern and coexist with obesity; while in Mexican–American communities micronutrient deficiencies also exist, the problem is less severe and obesity remains the larger problem. Also, there is an inverse relationship

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Joint U.S.–Mexico Workshop on Preventing Obesity in Children and Youth of Mexican Origin: Summary between socioeconomic status and obesity in Mexican Americans and the opposite is true among Mexicans. These differences might actually provide an opportunity for implementing interventions as more is learned from the experience in both countries. Resources and instrumentalization to address health problems are inadequate. Gaps in scientific data are not always filled through strict scientific rigor. Overcoming Barriers to Obesity Prevention As a parallel strategy to the joint solutions described in a following section, Mexico needs a strategy of solutions particular to the Mexican context. Working Group III addressed this question and suggested that all sectors—academia, government, industry, nongovernmental organizations (NGOs), and other stakeholders—have the opportunity and responsibility to develop an obesity prevention strategy under a Mexican National Obesity Prevention Task Force. This strategy should take into account the urgency required by the continued rise in obesity and associated chronic diseases and the change in the Mexican government, and should be based on best available information. Martorell added that such a strategy could draw on the Institute of Medicine (IOM) report Preventing Childhood Obesity (IOM, 2005) but that it is equally important that the data generated in Mexico (e.g., from the National Health and Nutrition Survey) be used as a basis to support initiatives. Rivera reminded participants that there is a legal framework in Mexico based on a 2004 WHO (World Health Organization) General Assembly endorsement of the recommendations in the 2001 FAO (Food and Agriculture Organization) and WHO report Diet, Physical Activity, and the Prevention of Obesity (WHO, 2004). In this sense, Mexico has a commitment with WHO to develop a national strategy for obesity prevention, and therefore the efforts should continue. Rivera also suggested that the Mexican National Obesity Prevention Task Force and a U.S.– Mexico binational initiative could work synergistically. The following are elements of the suggested Mexican National Obesity Prevention Task Force that reflect the discussions of Working Group III and further plenary discussions regarding activities where progress is needed in Mexico before (or concurrent to) the implementation of a binational agenda: Increasing the awareness of the obesity problem. Public awareness in Mexico needs to be increased so that individuals are more receptive to preventative interventions. This could be done through a coordinated effort by the public health community, media, and government. Some participants

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Joint U.S.–Mexico Workshop on Preventing Obesity in Children and Youth of Mexican Origin: Summary believed that the collection of survey data with latest trends in obesity prevention (ENSANUT data), associated risks for other chronic diseases, and cost estimates of the obesity epidemic could be used as a basis to raise awareness among the healthcare, community and government sectors, and other decision makers. Developing and implementing a national policy for obesity prevention. This national policy will have continuity regardless of changes in government. The school system in Mexico provides an extraordinary opportunity to implement changes that will affect a large part of the population (e.g., school foods or physical activity interventions). However, regulations or guidances will not help unless there are not financial and human resources to implement them. Also, in some cases, current regulations in Mexico are not always implemented or enforced. Regulations or guidances could follow those already implemented in other countries but considering also the Mexican political, social, and cultural context. Participation of the community sector. Members of the community need to be educated, organized, and empowered to advocate to the government and funding institutions about health issues, and obesity in particular. Such an effort could assist the community sector in playing a pivotal role in advocacy and imparting positive changes. Community advocacy also provides an additional opportunity for collaboration among community, industry, and academic sectors. For example, the community could collaborate with industry on educating parents on obesity prevention. Conducting a careful assessment of human resources. Mexico faces a dual burden of disease where micronutrient deficiency and obesity coexist. This new challenge calls for a careful assessment of human resources needs; for instance, there may be a need for experts in research evaluation, intervention efficacy, program management, and implementation. The United States can play an important role in providing assistance to build that capacity with appropriately designed training opportunities. The “Information and Research Gaps” section also provides some lead to specific research needs that might warrant innovative skills and training. Building trust among various sectors. The group recognized that the only path toward long-term solutions for a multisectorial problem such as obesity must include collaboration and trust among sectors (e.g., industry, government, schools, and community). A mechanism by which such collaboration is initiated, Martorell noted, is the IOM’s Food Forum, a successful model for building trust and dialog among different sectors. The Food Forum is composed of leaders from academia, government, industry, and consumers who meet regularly to discuss issues of common interest. When conducted under the umbrella of an independent institution like IOM, such a gathering fosters dialog and collaboration in a neutral and safe environment. Mutual trust is built by sharing different perspectives and through

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Joint U.S.–Mexico Workshop on Preventing Obesity in Children and Youth of Mexican Origin: Summary maintaining a dialog over time. Other specific interventions to build trust are described in the sections “Role of Families and Communities” and “Role of Industry.” Strengthening the local public health capacity to collaborate with other sectors will help advance an obesity prevention agenda in multiple sectors. Providing recommendations to decision makers based on scientifically-based research. It was the opinion of a number of participants that a study like the 2005 IOM report Preventing Childhood Obesity: Health in the Balance for the population of Mexican origin could be led by an authoritative Mexican institution that could make recommendations on nutrition and public health based on scientific evidence as well as highlight specific areas that warrant further research. For example, what are the risk factors (e.g., diets, socioeconomic status) in the different areas of Mexico that result in prevalence differences in the north and south? An effort could also be specifically directed to educating legislators about the obesity epidemic and potential solutions. Developing prevention strategies. All sectors in Mexico have the opportunity and responsibility to develop strategies with a sense of urgency, taking into consideration the positive timing and based on the best available science and also drawing from the IOM report, that is, adapting the recommendations to the Mexican context when appropriate. In this respect, collaborations among all sectors are very important including the food industry but also other sectors such as food retailers and fast food chains. Specific Interventions to Prevent Obesity in Children and Youth of Mexican Origin Several participants maintained that the main premise for an obesity prevention strategy is that the causes of obesity follow on several levels an ecologic, causal model (see Figure 2-7) and, therefore, the strategy to mitigate the epidemic should be multilevel, multisectorial, and multidisciplinary. It also is important to recognize that interventions need to be based on the best available evidence and on data from solution-oriented research designs instead of problem-oriented research designs. Participants described solution-oriented research as research designs that lead directly to policy or practice changes that also include an evaluation component. Evaluating the efficacy of interventions and programs in preventing obesity is an important criterion to make decisions about which interventions merit further investment. The following sections present a summary of the perspectives and experiences of U.S. and Mexican leaders from various sectors, including community, schools, industry, and government, plus other discussion items that were raised by workshop participants.

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Joint U.S.–Mexico Workshop on Preventing Obesity in Children and Youth of Mexican Origin: Summary Role of Families and Communities Carmen Rita Nevarez, Public Health Institute, provided a U.S. perspective on the distinct role that families and communities play in preventing childhood obesity. Changes in behavior do not happen easily or without the collaboration and agreement of families and communities. Nevarez addressed methods to engage the community in building healthier environments and emphasized ideas for necessary resources, tools, and skills. Nevarez spoke from her broad experience in working with Californian communities, where there is an emphasis on environmental changes that encourage healthy choices by making them the easier alternatives. An example of the importance of community participation is demonstrated by the recent passage in California of two bills that create the strictest standard yet in the United States for food and beverages sold in public schools. The bills ban the sale of soda and other sweetened beverages in public schools starting in 2009. This outcome was possible because of community collaboration. Such collaboration included community members’ participation in congressional committee hearings where young people, pediatricians, parents, and teachers expressed their health concerns and challenges in following a healthy lifestyle. The passage of those bills took a concerted effort to organize, educate, and bring the community to a level of trust and understanding so they could participate in the legislative process. It is clear that together with the public health authorities and experts, community leaders can transmit their ideas on necessary changes for communities to become healthy. A current initiative in California is the Partners for Health project, sponsored by the California Endowment (a private California foundation that focuses on decreasing health and healthcare disparities). Under the Healthy Eating, Active Communities2 initiative, five communities were selected to engage in school and community projects such as increasing the nontraditional exercises available at schools (e.g., walking to golf lessons) or evaluating cafeteria foods (e.g., increasing the fruits and vegetables options), turn- 2 Healthy Eating, Active Communities (HEAC) is a four-year $26 million initiative of the California Endowment, the state’s largest health philanthropy. HEAC’s goal is to reduce disparities in diabetes and obesity by using community models and statewide policy advocacy to improve nutrition and physical activity environments in schools, neighborhoods, marketing and media, and by healthcare providers. Most of the places where HEAC is active are heavily populated by Mexican Americans. Improvements prompted by HEAC include enforcement of school nutrition and physical education standards, school wellness policies, health-conscious city planning, healthier options in vending machines in public venues, a teen recreation center, bike paths, farmers markets, and promotoras establishing a neighborhood playground (http://www.healthyeatingactivecommunities.org).

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Joint U.S.–Mexico Workshop on Preventing Obesity in Children and Youth of Mexican Origin: Summary ing the teachers into the physical activity counselors, and assessing the health status of their environment. The process by which a disenfranchised, poor, Latino community can engage in community initiatives, particularly related to health, involves gaining the trust of a promotora—a trained individual who communicates healthy messages and helps others learn to be advocates by teaching people about health and communication skills, especially on how to communicate with authorities. The role of the promotoras is key to building trust between community members and authorities and should be supplemented with regular meetings among community members and the city council or the local health department. Finally, and most importantly, youth should contribute (and be accepted for) their energy, ideas, and participation— they are invaluable resources to influence decision making and changes in the community. As mentioned previously, many regulations, health policies, and initiatives on preventing obesity and other health problems originate from social, nongovernmental, or consumer organizations that are supported by the community. Mexican workshop participants reiterated that in Mexico there unfortunately is not a sector that supports and represents the interests of consumers; therefore, Mexico’s efforts in developing an obesity prevention roadmap in which community engagement is a key factor are limited but should be pursued. Role of Schools Guillermo Ayala, Mexican Secretaria de Educación Pública (Ministry of Public Education), presented a Mexican perspective on how schools could contribute to the implementation of solutions for mitigating the obesity epidemic. In his view, schools play a role not only in nutrition education but also in the development of critical thinking skills (e.g., decision-making skills and those required to overcome social pressure). Mexican schools follow the regulations published in the Federal Official Newspaper (Diario Oficial de la Federación) in 1882. The functions of the Social Participatory School Board (Consejo Escolar de Participación Social en las Escuelas) are described in the Guidelines for the Organization and Functioning of Elementary Schools and Adult Education (Lineamientos para la Organización y Funcionamiento de las Escuelas de Educación Básica, Inicial, Especial y para Adultos). The Board’s members are the school principal, parents, representatives of their associations, teachers, and union representatives working in collaboration with interested members of the community. In this venue, Ayala said, the participation of the private sector (e.g., the food industry) would be beneficial.

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Joint U.S.–Mexico Workshop on Preventing Obesity in Children and Youth of Mexican Origin: Summary Ayala presented data on the prevalence of obesity in schools—information that reiterates the urgency of the problem. An assessment of the school situation found that in 2004–2005, the prevalence of obesity among preschool children was only 2 percent and remained low in 2005–2006. However, in elementary schools, the prevalence of obesity in 2005–2006 was 24 percent—a worrisome increment given the detrimental consequences to health, according to Ayala. In terms of physical activity, the General Board of Physical Education (Dirección General de Educación Física) developed a physical activity program in Mexico City schools that stimulates daily physical education before classes start and evaluates its efficiency. Unfortunately, as acknowledged by other participants, some past policies on physical education have led to a situation where some Mexican states provide insufficient levels of physical education. The national program of physical education for the whole country should be seen as an opportunity and should remain in place regardless of the changes in the government. Institutions like SEP (Secretaria de Educación Pública, Secretary of Public Education) and Instituto Nacional de la Salud Pública (INSP) as well as the healthcare sector in general would serve as advisors to the government in developing a national program. Another intervention that is proving to be invaluable in schools is involving children in health programs. For example, the Interdisciplinary Committee on Diabetes, Obesity and Cardiovascular Diseases (Comité Interdiciplinario para la Diabetes, Obesidad y Enfermedades Cardiovasculares) has initiated a program that includes prediagnosis of obesity and realistic, practical objectives for decreasing obesity in schools. Ayala added that to guarantee progress, schools need to develop an integrated system—one that includes schools as well as physicians—around promoting and maintaining health needs. In that regard, researchers should find motivational factors for physicians so that the doctors monitor obesity in their routine check-ups. Changes toward a healthy lifestyle can be encouraged in many ways but the cooperation of physicians is key to initiating and continuing those changes. Diana Bonta, Kaiser Permanente, provided examples of viable, yet challenging, next steps to increase the healthcare sectors participation in preventing obesity like requiring body mass index (BMI) be part of the medical chart and training physicians to communicate about obesity. In addition to interventions, there are systems research projects at the schools conducted primarily by INSP and the General Board of Epidemiology (Dirección General de Epidemiología) from the Ministry of Health. Information based on their research has led to the implementation of school interventions. For example, the General Board of Epidemiology (Dirección General de Epidemiología) from the Ministry of Health, is conducting a study on overweight and obesity control in the schools of Mexico City from

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Joint U.S.–Mexico Workshop on Preventing Obesity in Children and Youth of Mexican Origin: Summary a clinical perspective. Ayala expects that new recommendations for interventions will continue to be based on updated, improved surveys conducted in collaboration with the schools. In addition, the studies will undoubtedly result in a new research agenda for the 2006–2007 school cycle that will incorporate cross-sectional and longitudinal studies for collecting data on many aspects of changing behaviors. The school systems need clear, efficient recommendations for interventions. Collaboration with industry would be beneficial in the developing of such recommendations. Ayala and others recognized that a more severe limitation to increasing the level of physical education classes in schools is the lack of economic resources to invest in physical activities, sports facilities, and didactic materials for the teachers. There are some programs for physical education, but they have been neither applied nor evaluated. There is a general sense that an additional limitation to intervention progress at the schools is the amount of bureaucracy. Russell Pate, University of South Carolina, added a general comment on other broader, intrinsic challenges related to sustaining an active life for the long term, that is the provision of experiences that not only provide enjoyment and a sense of competence as children but also later as adults. Although there is a lack of research data to support the long-term impact of exercising as a child, Pate asserted that it contributes to lifelong good habits resulting from increased confidence in an ability to be active and enjoyment in the activity. This is an area where the United States needs improvement, too, because as many as 40 percent of high school students report not being involved in interscholastic sports. Although, some preventive actions are being implemented by improving nutrition and guaranteeing daily physical activity, educating children (as well as teachers and the general public) on obesity prevention through effective campaigns is critical. Ultimately, there is still not enough nutrition information in school programs. Role of Industry What actions can industry, restaurants, caterers, media, and advertising and marketing agencies take to continue to reverse and prevent the obesity epidemic in youth and children? Should the food industry produce healthier food or try to modify behavior in children and youth; should the industry take an active role in encouraging parents and community members to be role models? This section summarizes thoughts on these questions from a U.S. and Mexican perspective. Food industry. Lance Friedman from Kraft Co. presented his perspective and a summary of activities initiated by Kraft Co. The following are key elements of Kraft’s health and wellness strategy: healthier food is not only

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Joint U.S.–Mexico Workshop on Preventing Obesity in Children and Youth of Mexican Origin: Summary good for public health but also can be translated into company revenue; self-regulation of the food industry can be an effective way of providing healthy choices to the public; and given the complexity of the obesity problem, collaboration is the only real path to success in providing the public with appropriate information and healthy food choices, in marketing campaigns that foster behavioral changes, and in implementing other food industry interventions. He referred to Preventing Childhood Obesity: Health in the Balance (IOM, 2005) for a comprenhensive account of measures that could be taken by industry. Two areas where Friedman envisions the role of industry are gaining the trust with stakeholders and the public and increasing the range of healthy products (e.g., Kraft’s “better for you products”). To grow public trust in industry, an advisory board was established to develop program ideas in the following four areas: improving the overall nutrition profile of products, providing more and better consumer information, practicing responsible marketing to help children to make the right choices, and participating in advocacy and dialogue. Among the many initiatives to include in the “better for you products” campaign, a critical one is to encourage consumption of healthier products through the development of specific logos identifying healthier products such as the “Sensible Solution” products, which meet nutrition standards like calorie, fat, sugar, and sodium reduction; an increase in beneficial nutrients (such as calcium, whole grain, fiber, and protein); or inclusion of functional benefits (such as heart health). A parallel program—“Elección equilibrada”—has been implemented in Mexico. In terms of marketing, the U.S. and European agencies continue to deliberate on appropriate food marketing policies for children. Extending healthy lifestyle programs beyond food products into community programs (e.g., “Salsa Sabor y Salud” and “Alimentarnos para vivir mejor” in the United States and Mexico) can be effective. Evaluations of “Salsa Sabor y Salud” and of “Sensible Solutions” have demonstrated positive results (although improvements will be needed over time). Friedman reemphasized that collaboration is the only way to obtain support and effectiveness from industry interventions. Enrique de la Madrid, Mexican Council of Food Product Manufacturers (Consejo Mexicano de la Industria de Productos de Consumo) and member of the Alliance for a Healthy Life (Alianza por una Vida Saludable, a group of seven industry associations that have initiated a response to the obesity issue), presented his views on the food industry’s role in obesity prevention. Alianza por una Vida Saludable is composed of associations linked to consumer and food products, health, restaurant, retail, and media associations. De la Madrid agreed with Friedman regarding the importance of partnering with groups like the Alliance for a Healthy Life—which works

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Joint U.S.–Mexico Workshop on Preventing Obesity in Children and Youth of Mexican Origin: Summary prices of specific commodities and further consequences in patterns of food consumption cannot be overlooked. López agreed with this proposition and indicated that there is an opportunity to define a binational strategy that can impact international trade policies. INFORMATION AND RESEARCH GAPS Working Group II discussed areas where there are information gaps critical to making progress toward lessening the prevalence of obesity among children and youth. The goal of this section is to frame the information needs into a research agenda that can be translated into action. As pointed out by Arturo Jimenez, Universidad Autónoma de Baja California, in order for an obesity prevention program to succeed, more researchers from the different academic institutions and the leaders of these institutions should participate in the development of the program so that they can convey the findings to the communities. Research institutions need to maintain long-term relations with the community and strive to link research to actions. Thomas Robinson, Stanford University, summarized the discussions of Working Group II on research needed to further progress in reversing childhood obesity. He noted that research and development on interventions needs to encompass all life stages. The group did not find a consensus on which life stages should receive greater priority; however, early childhood appeared to be one critical stage. Other stages that would benefit from further research are prenatal stages (e.g., investigating interventions that could help prevent gestational diabetes). Working Group II also related that research should focus on school-based and community-based interventions, which might be particularly effective in preventing childhood obesity. Regardless of the selection of intervention venues or life stages, industry was seen as a key player in the process to translate research findings to feasible interventions. Questions were also raised on how industry could engage in decision processes and interventions that are attuned with requests and expectations from the public and healthcare community. The two main themes identified by the working group as needing further research (summarized below) were (1) risk factors associated with childhood obesity, particularly those related to behavioral patterns, along with strategies for interventions and implementations, and (2) design and implementation of studies to evaluate the efficacy of interventions and programs to prevent childhood obesity. Identifying Risk Factors, Interventions, and Implementation Strategies The broad questions that need investigation are the following: What interventions and strategies will be effective in obesity prevention among Mexican–American and Mexican children? How should these interventions

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Joint U.S.–Mexico Workshop on Preventing Obesity in Children and Youth of Mexican Origin: Summary be implemented? What specific research designs and testing interventions are needed? The working group recognized the lack of knowledge on effective interventions as was also concluded in the IOM report Preventing Childhood Obesity (2005). Although not discussed during the Working Group II session, Robinson noted the importance of evaluating the significance of potential outcomes of an intervention prior to actually conducting the study. That is, he insisted on the importance of weighing the strength of each hypothesis and whether the outcome might result in a feasible solution. For instance, investigating safety in the community as a risk factor for obesity by looking at the level of safety and of physical activity in children might not have any value because, regardless of the outcome, an increase in safety will always be pursued. Efforts in these types of studies should not be a priority. A better approach would be to design a specific intervention that increases safety and to analyze its effect on physical activity; such a study could provide information about the efficiency of the intervention and can be the basis of decisions about whether or not to implement it. To avoid futile results as in the example above, researchers should always question whether the result of the study ultimately is going to lead to changes. In connection to this, the concept of solution-oriented research as research designs that lead directly to policy or practice changes that also includes an evaluation component was supported by the Working Group II. Behavioral Research One area that was identified by the working group as critical is experimental behavioral research on motivation and eating behaviors. Some participants insisted that messages about the health consequences of maintaining a healthy weight are not effective incentive factors, and that sociocultural factors such as beauty, fun, wealth, and success are much more likely to lead to changes in behavior. Understanding these behavioral factors is key to develop interventions that will result in long-term diet and physical activity attitude changes. This research should be conducted with subgroups of Mexicans and Mexican Americans, differing by location (urban versus rural), by socioeconomics, esthetics, and geographic origin. Other factors to consider are the length of the acculturation process for immigrants in the United States and the migration patterns. Acculturation factors might contribute to the diet and physical activity patterns of immigrants; if this is the case, then the group noted that searching for incentives to moderate any negative effect of the acculturation factors and values of certain subgroups on populations on diet and physical activity levels would be an important focus of behavioral research.

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Joint U.S.–Mexico Workshop on Preventing Obesity in Children and Youth of Mexican Origin: Summary Participants also noted that marketing research data would be a valuable resource to begin to answer the questions above and developing interventions. The use of market data for developing interventions was recommended in the 2005 IOM report Preventing Childhood Obesity. The difficulty in obtaining such data from food companies was raised. Access to data from marketing research firms and food, beverage, and restaurant companies is a challenge since they are not in the public domain. Some databases are available for a price but with many restrictions on the use of that information. IOM’s Vivica Kraak reported limited success in receiving proprietary data from market researchers and companies to inform the IOM report on food marketing to children and youth during the two years that it took to complete. The IOM report recommended creating a mechanism for accessing marketing research data so that it can be used to develop social marketing and public education campaigns (IOM, 2006). Participants also observed that companies conducting market research for Mexico should also contribute to this endeavor. For example, Khan noted that the company MPD (which also started the Nielsen TV Index) has data sets not only of food patterns in restaurants or at home but also from personal history surveys with information on physical activity. This is a phenomenal set of marketing data that are sponsored by industry but unfortunately are very expensive to obtain. The food industry, as their customers, could devise ways to make it more easily available. De la Madrid, representing the food industry, mentioned the formation of a research industry group for particular topics that could assess and share specific research findings as the best strategy to allow information exchange. Behavioral research is critical and should be designed not only to describe but also to understand attitudes of consumers so that intervention development can include effective motivational factors. Research to help identify factors that increase behavioral adherence and maintenance is important but largely nonexistent. Following basic behavioral studies, researchers should conduct feasibility or pilot studies to design and test intervention strategies and to identify potential barriers and facilitators of behavior changes. These studies should be conducted before a randomized control trial to avoid pitfalls or failures in the more costly, randomized control study; to help refine designs so researchers know the parameters and factors to consider; and to identify and possibly manipulate mechanisms (often called mediators of interventions). Mediators may be characteristics such as language, sex, or origin; in essence, pilot studies increase the chances for success when the randomized trial is conducted. Although randomized control trials should be attempted, the working group recognized the challenges and expense of following control studies in a real-life scenario. In addition, the working group suggested that once there is more

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Joint U.S.–Mexico Workshop on Preventing Obesity in Children and Youth of Mexican Origin: Summary evidence that supports the association of specific risk factors to obesity, then a much broader testing of these interventions should be conducted in a less controlled, more real-life scenario. Research on Other Risk Factors At the present time, information on obesity-linked risk factors is scarce, so interventions are developed based on suggested associations between certain factors and obesity. The current guidelines, recommendations, and initiatives have been developed with the best available science, but there is not confirmation that they are the most appropriate ones. Therefore, there is a need to collect more data on risk factors so that eventually recommendations regarding interventions are stated with sufficient evidence. For example, research on the effects of dietary content, eating patterns, physical activity and inactivity levels, and patterns leading to obesity prevention and weight control in already obese children should continue to be investigated so that a clearer picture of the factors and relationships among them emerges. What is the amount of physical activity that is really needed for weight control or prevention? Are the dietary guidelines in the United States and Mexico appropriate for weight gain control or prevention? These questions remain unanswered but could be addressed through experimental studies or prospective studies with appropriate measurements. Evaluating Interventions and Programs An important aspect of reversing the obesity epidemic via interventions is to evaluate programs already implemented, whether in other countries or locally, with the objective of gaining knowledge from those experiences and applying that knowledge to develop improved or new strategies. For example, the design and selection of pilot studies should draw from the findings derived from other research and experiences on obesity or other health-related intervention and program implementations. Much of the discussion focused on the importance of studies for evaluation of macrolevel interventions (e.g., evaluation of governmental policies and actions such as food and nutrition regulations, taxations, trade policies, urban planning policies, dietary and physical activity guidelines, or other public health initiatives) with special emphasis on the intense activity in European countries, where they tend to favor governmental interventions more often than in North America. Evaluating their programs for efficacy and feasibility might be very beneficial for leaders in all sectors in both the United States and Mexico. Evaluation also applies to industry’s initiatives to prevent obesity. For example, evaluating the responses of consumers to voluntary industry

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Joint U.S.–Mexico Workshop on Preventing Obesity in Children and Youth of Mexican Origin: Summary changes (e.g., new products and packaging) will provide a deeper insight on consumer behavior. As mentioned previously, this might improve refinement of future interventions. Ideally, when evaluating the outcomes associated with macrolevel interventions, experimental designs will be similar to the ones conducted on intervention effects except they will be conducted before and after an innovation or policy was introduced. Furthermore, cross-sectional comparisons among countries, states, communities, and schools will add value to the evaluation. During the plenary discussions Simon Barquera, INSP, mentioned that contrary to what happens in other Latin American countries, broad educational programs in Mexico cannot be evaluated because they do not have specific goals. For example, a program for physical activity and nutrition in Chile has consistent goals in terms of obesity prevalence for the years 2010, 2015, and 2020. This is not contemplated in the Mexican programs. In addition, some of these programs have been implemented only for a very short time. Barquera concluded that the lack of consistent goals in conjunction with a short implementation period precludes program evaluation; in addition he recommended that food industry programs should also include evaluation. These findings could be shared with others in the community and serve as basis for continued program improvement. Evaluating food programs was one of the research needs specifically discussed by Mexican participants. Hernandez noted that an analysis of the foods distributed by government nutrition programs such as LICONSA and DICOSA in Mexico would help researchers understand the effects of those type of foods and programs on obesity. For example, LICONSA sells subsidized foods—such as pasta and sweetened beverages—that could contribute to an increase in obesity prevalence, especially in poor and rural areas. Teresa González de Cossio, INSP, added that these programs do not distribute perishables because of long distribution distances (e.g., the main hub in Mexico City often is far from the food’s destination). Better strategies for food distributions are needed. Furthermore, she said that in Mexico weight for age is used to evaluate malnutrition and eligibility for participation in food programs; the use of this indicator might erroneously include in these programs children who do not suffer from malnutrition. Various evaluations of nutrition programs in the United States suggest that their effects on the propensity of obesity are either beneficial or neutral; however, analysts note that many of the studies were not designed to assess the programs for their effects on obesity and therefore better study designs for evaluating these programs are needed.

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Joint U.S.–Mexico Workshop on Preventing Obesity in Children and Youth of Mexican Origin: Summary OPPORTUNITIES FOR COLLABORATION: A BINATIONAL, COMMON AGENDA This section addresses the ultimate objective of this workshop—to explore opportunities for collaboration between the United States and Mexico with the common objective of preventing progress of the obesity epidemic among Mexican and Mexican–American children and youth on both sides of the border. Sepúlveda reminded the audience that, in addition to positive examples of collaborative research, the IOM’s Preventing Childhood Obesity report provides an extraordinary example and incentive to adapt those recommendations in Mexico and to follow closely the changes in obesity among the Mexican population in the United States after interventions recommended might be implemented. This section is organized as follows. Working Group III’s central proposal regarding a binational program is followed by some specific areas in which collaboration would be mutually beneficial. The summary of the presentation by Eileen Kennedy, Tufts University, highlights examples of collaboration among different sectors and levels. Proposed Collaborations Working Group III proposed the creation of a joint U.S.–Mexico Obesity Prevention Task Force as a cost-effective, multisectorial initiative. Some participants proposed that the task force could be expanded to include Canada, creating a North American Task Force. The responsibilities of the task force as summarized by Working Group III are listed in Box 3-1. BOX 3-1 U.S.–Mexico Joint Obesity Prevention Task Force: Responsibilities According to Working Group III, the responsibilities of an obesity prevention task force would include Develop a strategy to prevent obesity. Promote an obesity agenda, including a specific timeline and responsibilities. Promote policies and norms that will allow environmental modifications, such as schools, worksites, cities, and others. Develop an educational strategy in accordance with the previously stated policies and general agenda.

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Joint U.S.–Mexico Workshop on Preventing Obesity in Children and Youth of Mexican Origin: Summary Specific activities identified by Working Group III as potential collaborative elements of a binational agenda in preventing childhood obesity are advocacy, funding, labor force training, scientific research, program evaluation, and ensuring consistency in programs and messages. Specific examples of collaborative elements suggested by individual participants are explained further in Box 3-2. Communications among task force members could be facilitated through conferences and the Internet so that the information on obesity prevention can be included in ongoing scientific and programmatic exchanges. Collaborations that Work: Activities at Tufts University Friedman School of Nutrition Science and Policy As mentioned above, Kennedy highlighted examples of collaboration among different sectors (e.g., industry, government, schools) with a common goal of a healthier environment and examined three different levels that have experienced collaborative success—community, national, and international. Community Level The development of collaborative strategies at the community level are based on three assumptions: the prevention of overweight and obesity is complex, small but sustainable changes occur over time, and healthy diet and physical activity are necessary components of obesity prevention. The community-level work is based on multidimensional strategies that combine the public and private sectors; however, perhaps work on the community level also needs newer paradigms to embrace because individual responsibility alone does not explain the current obesity epidemic. Although this idea is predominant among experts in this field, it is not widely shared among policy makers, who continue to put greater emphasis on individual responsibility. An obesity intervention—called “Shape up Somerville”—was led by Tufts University in the community of Somerville, Massachusetts, and was geared toward children in first, second, and third grades; this intervention was successful in spurring environmental changes. Somerville has a low-income population and a very ethnically and racially diverse large Hispanic population composed of Mexican Americans (both recent and long-time immigrants), Guatemalans, Salvadorians, and Puerto Ricans as well as a large Asian population. Kennedy explained that the driving force behind this intervention was the realization that individual behavior change was not sufficient as a prevention strategy and that a larger environmental strategy using the social economic model was needed.

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Joint U.S.–Mexico Workshop on Preventing Obesity in Children and Youth of Mexican Origin: Summary BOX 3-2 U.S.–Mexico Joint Obesity Prevention Task Force: Suggested Elements Participants in Working Group III listed several elements for a U.S.– Mexico Joint Obesity Prevention Task Force. These were further expanded with specific examples of collaboration by individual participants and include: Advocacy. There is an urgent need to convey the following message to the general public and more specifically to funding institutions and government—obesity is a major problem in Mexico and the United States and has major economic and health consequences. Academia, industry, and the health sector need to transmit this message with efficacy and determination using scientific data as basis. The joint U.S.– Mexico Obesity Prevention Task Force could undertake such an educational campaign. Funding. There are funding opportunities on both sides of the border. Collaboration in identifying potentially beneficial resources will be an important endeavor. Some potential funders, alone or in partnership, might be the International Life Sciences Institute, the Pan American Heath Organization, National Institutes of Health, Conacyt, and industry. Training of labor force. Creating of solutions requires new skills for a new and complex problem that can be addressed only through interventions at all levels and through all sectors. The Mexican labor force needs to be trained to respond to the problems of malnutrition and obesity in implementation, evaluation, and management of programs. The Mexican–American community also needs to train its healthcare providers so that they are knowledgeable about the Mexican culture and able to give guidance on lifestyles conducive to overall health and weight management. Research. This area needs multidisciplinary, expert teamwork. Examples of research areas that could be conducted jointly are: Develop a system of standard instruments including growth curves, indicators of obesity that will enable comparative analysis of levels, tendencies, and health nutritional problems. Also, a joint system of indicators for other health nutritional problems that will enable comparative analysis was suggested. Conduct comparable surveys in the United States as well as in Mexico so data can be shared and compared. Extend the system to other countries in North and Central America. What is the best parameter to use that indicates childhood obesity? Is it BMI, waist circumference, abdominal obesity, or others? Or a combination of them? Conduct epidemiological studies in Central and North America.

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Joint U.S.–Mexico Workshop on Preventing Obesity in Children and Youth of Mexican Origin: Summary Conduct studies to explore the influence of acculturation on the prevalence of childhood obesity, that is, the influence of changes in behavior that Mexican Americans experience as they integrate in the U.S. society and they adopt U.S. social norms and habits. Research on social norms of other countries in Europe and Australia that do not promote an obesigenic environment to evaluate their application to the United States and Mexico. Evaluate the cost for consumers of new products. Analyze cost of interventions (e.g., nutrition interventions) and cost of obesity, also taking into consideration the associated comorbidities. Program evaluation. This area also needs multidisciplinary, expert teamwork. Examples of evaluation that could be conducted jointly are: Introduce measurements of obesity indicators or other health outcomes as elements of intervention and programs so they can be evaluated. Identify obesity prevention goals at short-, middle-, and long-term. For example, physical activity programs have been implemented in Mexico but only if they have goals can they be evaluated. Evaluate the effect on obesity prevalence and other health outcomes of subsidized food programs such as the Mexican Oportunidades and PrevenIMSS, and school breakfast programs or the U.S. Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). As such, they should include measurements to prevent obesity. Evaluate the impact of the regulations and programs on obesity and other health outcomes. Evaluate macro-level interventions in different countries and form collaborations to share findings. Consistency in programs and messages. As the United States and Mexico increase their cultural and commercial exchanges, actions in both countries need to occur simultaneously so that inconsistent and counterproductive policies, guidances, educational programs, and other efforts are avoided. The need for consistency applies to the many ongoing programs mentioned in the section “Specific Interventions to Prevent Obesity in Children and Youth of Mexican Origin.” Examples are: Development of consistent propriety logos in food items so that the public associates them with a specific health benefit (e.g., a reduction of trans fatty acids content in foods). Harmonizations of some regulations, such as the labeling regulations. Health promotion messages and educational materials that reach Mexican and Mexican–American youth via radio, television, the Internet, and printed media could be adapted and shared.

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Joint U.S.–Mexico Workshop on Preventing Obesity in Children and Youth of Mexican Origin: Summary Community members, healthcare providers, media, restaurants, and other private-sector groups were involved in a three-year effort to influence the children’s overall activities in their homes, before school, during school, and in after-school programs. Six city departments, 86 organizations and businesses, 320 community members, and 20 restaurants were involved. The initiative included activities such as assessing breakfast foods; incorporating walk-to-school programs that were overseen by adults in the community; engaging parents; and making other changes in physical activity, food services, and curriculum in the classroom or after school. As a result, there were major modifications in school food service (e.g., additions of a la carte items and more fresh foods), curriculum recess, and after-school and at-home activities. Data from the evaluation of this program are currently being analyzed. At base line, 40 percent of the first, second, and third graders were either at-risk for or overweight. Although the evaluation analysis is still in progress, initial findings for the first three years of the intervention show a significant decrease in obesity when compared with other school rates that are increasing. This initial result of a decrease in obesity prevalence surpasses the outcome expectation, Kennedy said, which was a slow down in the increase of obesity, rather than an actual decrease. Such positive achievement shows the potential for future successes in decreasing rates of obesity with the implementation of community participatory approaches. She also noted that in order to realize all the benefits, researchers need to look beyond changes in the prevalence of obesity and factor in additional benefits, such as those from healthcare savings derived from improvements in associated diseases (e.g., asthma). During the discussion period, many questions arose on the cost and benefits of such an intervention and on the potential increase of costs to the school and families. Kennedy acknowledged the potential for higher costs of introducing a diet higher in fruits and vegetables. She said that one interesting note was that because of the higher costs of food items, negotiations between the city government and vendors took place that finally resulted in vendors compromising profits in turn for an increase in client numbers. During plenary discussions it became clear that there is a real gap on data on cost-effectiveness of nutritional interventions. Finally, she concluded that programs like this have an enormous potential for exploring commonalities as well as differences in U.S. and Mexican community approaches. Analyzing the data sets could provide universal lessons on unique environment situations. National Level National approaches that reach a much larger population are clearly desirable. One approach by Tufts University has been to implement interventions to change dietary behaviors at point of purchase. The U.S. Depart-

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Joint U.S.–Mexico Workshop on Preventing Obesity in Children and Youth of Mexican Origin: Summary ment of Agriculture and Tufts University in conjunction with Safeway (a nationwide supermarket chain that reaches 30 million consumers per year) have entered into a cooperative agreement to implement specific interventions. This approach—which suggests an increase in trust between the government and private sector—is based on the supermarket’s historical data for motivational factors behind shopping (e.g., price, convenience, time, health). The resulting multiprong intervention includes in-store promotions, mailings, and kiosks. During the discussion period it was mentioned that an intervention like this could also be adapted in Mexico. International Level The International Union of Nutritional Sciences (IUNS) is a worldwide nutrition body that represents 156 different countries and various different scientific bodies. IUNS has asked Tufts University to organize a task force to identify newer paradigms for inducing public- and private-sector collaborations and to test them on countries that are more receptive to collaboration; this task force could make an enormous contribution as a model initiative for an international and bilateral collaboration. REFERENCES IOM (Institute of Medicine). 2005. Preventing Childhood Obesity: Health in the Balance. Washington, DC: The National Academies Press. IOM. 2006. Food Marketing to Children and Youth: Threat or Opportunity? Washington, DC: The National Academies Press. Norma Oficial Mexicana. 2005. NOM-043-SSA2-2005, Servicios básicos de salud. Promoción y educación para la salud en materia alimentaria. Criterios para brindar orientación. WHO (World Health Organization). 2004. Global Strategy on Diet, Physical Activity, and Health. Report No. WHA57.17. [Online]. Available: http://www.who.int/gb/ebwha/pdf_files/WHA57/A57_R17-en.pdf [accessed May 7, 2006].