MEASURING
PROGRESS IN
OBESITY
PREVENTION

Workshop Report

Committee on Accelerating Progress in Obesity Prevention

Food and Nutrition Board

INSTITUTE OF MEDICINE
OF THE NATIONAL ACADEMIES


THE NATIONAL ACADEMIES PRESS
Washington, D.C.
www.nap.edu



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MEASURING PROGRESS IN OBESITY PREVENTION Workshop Report Committee on Accelerating Progress in Obesity Prevention Food and Nutrition Board

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THE NATIONAL ACADEMIES PRESS 500 Fifth Street, N.W. Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Govern- ing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineer- ing, and the Institute of Medicine. This study was supported by a grant between the National Academy of Sciences and the Michael & Susan Dell Foundation; and Grant No. 61747 between the National Academy of Sciences and the Robert Wood Johnson Foundation. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the view of the organizations or agencies that provided support for this project. International Standard Book Number-13: 978-0-309-22239-6 International Standard Book Number-10: 0-309-22239-7 Additional copies of this report are available from the National Academies Press, 500 Fifth Street, N.W., Lockbox 285, Washington, DC 20055; (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area); Internet, http://www.nap. edu. For more information about the Institute of Medicine, visit the IOM home page at: www.iom.edu. Copyright 2012 by the National Academy of Sciences. All rights reserved. Printed in the United States of America The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin. Suggested citation: IOM (Institute of Medicine). 2012. Measuring Progress in Obe- sity Prevention: Workshop Report. Washington, DC: The National Academies Press.

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

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

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COMMITTEE ON ACCELERATING PROGRESS IN OBESITY PREVENTION1 DANIEL R. GLICKMAN (Chair), Executive Director of Congressional Programs, The Aspen Institute, Washington, DC M. R. C. GREENWOOD (Vice Chair), President, University of Hawaii System, Honolulu, HI WILLIAM PURCELL, III (Vice Chair), Attorney at Law, Nashville, TN DAVID V. B. BRITT, Retired President and Chief Executive Officer, Sesame Workshop, Fernandina Beach, FL JAMIE F. CHRIQUI, Senior Research Scientist, Health Policy Center, Institute for Health Research and Policy, University of Illinois at Chicago PATRICIA CRAWFORD, Director, Dr. Robert C. and Veronica Atkins Center for Weight and Health and Cooperative Extension Specialist and Adjunct Professor for the School of Public Health, University of California, Berkeley CHRISTINA ECONOMOS, New Balance Chair in Childhood Nutrition, Friedman School of Nutrition, Science, and Policy, Tufts University, Boston, MA SANDRA G. HASSINK, Director, Nemours Pediatric Obesity Initiative, A.I. DuPont Hospital for Children, Wilmington, DE ANTHONY B. ITON, Senior Vice President, Healthy Communities, The California Endowment, Oakland, CA STEVEN H. KELDER, Beth Toby Grossman Distinguished Professor in Spirituality and Healing, and Co-Director, Michael & Susan Dell Center for Healthy Living, University of Texas School of Public Health, Austin Regional Campus HAROLD W. (BILL) KOHL, III, Professor, Epidemiology and Kinesiology, University of Texas Health Science Center-Houston, School of Public Health, Michael & Susan Dell Center for Healthy Living, University of Texas at Austin, TX SHIRIKI K. KUMANYIKA, Professor of Epidemiology and Associate Dean for Health Promotion and Disease Prevention, University of Pennsylvania School of Medicine, Philadelphia PHILIP A. MARINEAU, Operating Partner, LNK Partners, San Francisco, CA VICTORIA RIDEOUT, President, VJR Consulting, San Francisco, CA 1 Institute of Medicine committees are responsible for the overall quality and accuracy of the report as a record of what transpired at the workshop. The report summarizes the views expressed by workshop participants, and the views contained therein are not necessarily those of the committee. v

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EDUARDO J. SANCHEZ, Vice President and Chief Medical Officer, Blue Cross and Blue Shield of Texas, Richardson, TX ELLEN WARTELLA, Al-Thani Professor of Communication, Professor of Psychology and Professor of Human Development and Social Policy, and Director of the Center on Media and Human Development at Northwestern University, Evanston, IL Study Staff LYNN PARKER, Scholar and Study Co-Director LESLIE J. SIM, Senior Program Officer and Study Co-Director ALEXANDRA BEATTY, Consultant HEATHER DEL VALLE COOK, Program Officer EMILY ANN MILLER, Associate Program Officer HEATHER BREINER, Research Associate MATTHEW B. SPEAR, Program Associate (until July 2011) ELENA OVAITT, Senior Project Assistant (from August 2011) ANTON L. BANDY, Financial Officer GERALDINE KENNEDO, Administrative Assistant LINDA D. MEYERS, Director, Food and Nutrition Board vi

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Reviewers This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the process. We wish to thank the following individuals for their review of this report: LISA M. KLESGES, University of Memphis ROBIN A. McKINNON, National Cancer Institute PAMELA M. SCHWARTZ, Kaiser Permanente GAIL WOODWARD-LOPEZ, University of California, Berkeley Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the final draft of the report before its release. The review of this report was overseen by MELVIN WORTH. Appointed by the Institute of Medicine, he was respon- sible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authors and the institution. vii

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Preface Obesity is recognized as a paramount public health problem. Obesity and overweight are associated with cardiovascular disease, diabetes, certain forms of cancer, and other conditions that are primary causes of mortality and morbidity in the United States. Obesity increased sharply during the last few decades of the 20th century, and while some statistics indicate that the increase has leveled off, at least in selected population groups, overall rates remain unacceptably high. People who struggle with weight as children are far more likely than other children to do so as adults, and excess weight can cause myriad health problems throughout the life span. Obesity also is especially prevalent among racial and ethnic minorities and in low-income communities. Those working to turn these trends around have faced an uphill battle. For example, the American public is awash in ever more sophisticated mar- keting of high-calorie foods and beverages with limited nutritional value, and many aspects of our society discourage the natural human impulse to move. These are among the reasons why attention is shifting from treating individual patients who are overweight or obese to addressing the powerful environmental and policy influences that operate at the community level and even more broadly in U.S. society. At the same time, researchers must move swiftly to keep up with—and measure—rapidly changing influences on food and beverage consumption and physical activity. To maintain the urgency of combating the obesity epidemic and to identify actions that can accelerate progress in this effort, the Institute of Medicine (IOM) convened the Committee on Accelerat- ing Progress in Obesity Prevention. Funded by the Robert Wood Johnson ix

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x PREFACE Foundation and the Michael & Susan Dell Foundation, the committee met for the first time in September 2010 with a charge to review IOM’s past obesity-related recommendations, identify a set of critical recommendations for future action, and recommend indicators of progress in implementing these actions. This report summarizes the presentations and discussions at a 1.5- day workshop held in March 2011 as part of the committee’s work. The purposes of the workshop were to explore and understand the ways in which measurement techniques, strategies, and data sources can impede or promote acceleration of progress toward prevention of obesity, and to understand what additional knowledge regarding assessments of environ- ments and policies is needed to support measurement efforts. The workshop brought together experts in many relevant fields, including public health, epidemiology, nutrition, media studies and communication, economics, psychology, and public policy. Given limitations of both time and scope, the workshop could not address all critical measurement issues. It is the committee’s hope, however, that this report will help illuminate the opportunities for and challenges in measuring progress in obesity prevention. We are grateful for the efforts of the expert speakers who contributed to the meeting (see the appendixes for the workshop agenda and biographi- cal sketches of the committee members and speakers). Special appreciation also goes to Jamie Chriqui, Steve Kelder, Bill Kohl, and Ellen Wartella, the committee members who volunteered their time and intellectual efforts to shape the workshop programs and identify themes and contributors. In addition, we give special thanks to Alexandra Beatty, consultant, who prepared a comprehensive draft of the workshop report; Emily Ann Miller, who edited the workshop report and coordinated the workshop planning and the production of the workshop report; Heather Breiner, Elena Ovaitt, and Matthew Spear, who assisted with the preparation and execution of the workshop and production of the workshop report; and Leslie Sim and Lynn Parker, who oversaw the work of the committee and assisted with the workshop planning. Daniel R. Glickman, Chair Committee on Accelerating Progress in Obesity Prevention

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Contents 1 Introduction and Workshop Goals 1 References, 3 2 Physical Activity and the Built Environment 5 Environmental and Policy Influences on Physical Activity, 6 Research, 8 Measurement Tools, 11 Collaboration with Non-health Sectors, 13 Surveillance, 13 National Objectives for Physical Activity Environments and Policies, 14 Measurement Tools and Gaps, 15 Analysis, Interpretation, and Dissemination of Data, 18 Recommendations, 19 References, 19 3 The Food and Nutrition Environment 21 Understanding Food Environments and Policies, 22 Measures, 25 Research, 28 Limitations of Measures, 28 Surveillance of Food Environments, 29 References, 36 xi

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xii CONTENTS 4 Looking Across Domains 39 New Tools for Childhood Obesity Research, 40 Body Mass Index, 42 Making the Economic Case for Obesity Prevention, 48 References, 53 5 Assessing the Impact of Marketing and Industry 57 Children, Media, and Advertising, 58 Media Use and Exposure, 58 Food and Beverage Advertising, 62 Measuring the Food Supply, 63 Evaluating Large-Scale Communication and Social Marketing Programs, 67 References, 71 6 Assessing State and Community Efforts 73 Reaching Policy Makers, 74 Community Strategies and Measures, 76 Fostering Research Collaboration, 79 Surveillance of Public Policies, 82 Assessing Impacts on Health, 85 References, 89 7 Disparities and Measurement 91 Disparities Related to Diet, 95 Evaluation and Measurement, 97 Assessment of Two Example Programs, 98 Disparities Related to Physical Activity, 103 Data Overview, 104 Measurement Issues, 105 The Role of Marketing in Disparities, 106 Research, 108 Discussion, 109 References, 111 8 Summary of Workshop Themes 113 An Ecological Approach, 114 Progress and Gaps in Available Measures, 114 Measurement Techniques and Methods, 115 Data Sources, 115 Moving Forward, 116 References, 118

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xiii CONTENTS APPENDIXES A Workshop Agenda 119 B Biographical Sketches of Committee Members 123 C Biographical Sketches of Speakers 133 D Acronyms and Abbreviations 143

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