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National Obesity Evaluation Plan

Why: Why develop a National Obesity Evaluation Plan? A National Obesity Evaluation Plan is essential for documenting progress, informing future direction on policy and environmental change at the national level, and providing support to state and community assessments, monitoring, surveillance, and summative evaluations.

What: What is a National Obesity Evaluation Plan? A National Obesity Evaluation Plan is a framework for evaluating progress in achieving the strategies recommended in the Accelerating Progress in Obesity Prevention report (IOM, 2012a) at a national level and serves as a model, template, or framework for state and regional evaluations. Much of the National Obesity Evaluation Plan, as distinguished from the evaluations of progress on more local efforts, centers on components and activities related to the development and maintenance of the infrastructure for continuous, nationwide monitoring and surveillance that regional, state, and community evaluations can use in their status assessments and progress evaluations.

How: How should the National Obesity Evaluation Plan be implemented? The National Obesity Evaluation Plan includes eight core activities: (1) establish key leadership, infrastructure, priorities, and timeline for implementation of the plan; (2) identify current federal monitoring, surveillance, and summative evaluation efforts; (3) harmonize and expand current federal monitoring, surveillance, and summative evaluation data collection; (4) develop new data collection instruments and systems to address gaps; (5) increase national and state capacity for monitoring, surveillance, and summative evaluation; (6) provide timely and relevant feedback from federal data; (7) ensure that federally funded programs include recommended indicators and common measures; and (8) encourage development and testing of new methodologies.



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6 National Obesity Evaluation Plan Why: Why develop a National Obesity Evaluation Plan? A National Obesity Evaluation Plan is essential for documenting progress, informing future direction on policy and environmental change at the national level, and providing support to state and community assessments, monitoring, surveillance, and summative evaluations. What: What is a National Obesity Evaluation Plan? A National Obesity Evaluation Plan is a framework for evaluating progress in achieving the strategies recommended in the Accelerating Progress in Obesity Prevention report (IOM, 2012a) at a national level and serves as a model, template, or framework for state and regional evaluations. Much of the National Obesity Evaluation Plan, as distinguished from the evalu- ations of progress on more local efforts, centers on components and activities related to the development and maintenance of the infrastructure for continuous, nationwide monitoring and surveillance that regional, state, and community evaluations can use in their status assessments and progress evaluations. How: How should the National Obesity Evaluation Plan be implemented? The National Obesity Evaluation Plan includes eight core activities: (1) establish key leadership, infrastructure, priorities, and timeline for implementation of the plan; (2) identify current federal monitoring, surveillance, and summative evaluation efforts; (3) harmonize and expand current federal monitoring, surveillance, and summative evaluation data collection; (4) develop new data collection instruments and systems to address gaps; (5) increase national and state capacity for monitoring, surveillance, and summative evaluation; (6) provide timely and relevant feedback from federal data; (7) ensure that federally funded programs include recommended indicators and common measures; and (8) encourage development and testing of new methodologies. 133

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INTRODUCTION T he Institute of Medicine’s (IOM’s) report Accelerating Progress in Obesity Prevention (APOP) (IOM, 2012a) presents a new way to frame obesity prevention by targeting policies, systems, and environ- ments, rather than focusing on individual change, as many previous recommendations have done. The evaluation of recommendations and strategies in the APOP report requires a similar frame of reference, ­ because prior evaluation efforts in the United States have focused predominantly on outcomes from i ­ndividual-level interventions and largely ignored or only superficially included monitoring of obesity prevention policies and environmental changes or surveillance of the effects of them. Thus, commitment to the APOP plan of action requires a concomitant commitment to an expanded view of evaluation that includes outputs, outcomes, and impacts at the environmental, systems, programmatic, and policy levels (see Chapter 3, Figure 3-1). As explained in Chapter 1, national evaluation needs to include (1) monitor- ing of obesity prevention policies, environmental changes, and other interventions; (2) surveillance of the changes in obesity and obesity-related behaviors, determinants, and consequences; and (3) summative evaluation of the effects of interventions on the incidence and prevalence of obesity and obesity-related behaviors, determinants, and consequences. In this chapter, the Committee sometimes uses the term evalu- ation to refer to all three of these functions. The inconsistent and varied use of these three terms in the various sectors, agencies, disciplines, and professions involved in obesity prevention necessitates that the Committee’s usage in this report will sometimes not match the way the term is used elsewhere. In addi- tion, the use of consistent definitions in this report complements the use of evaluation as a term in bio- logical and psychological research that lends itself more to individual-level studies and highly controlled experiments on the efficacy of interventions. Many initiatives have targeted obesity prevention, but monitoring, surveillance, and summative evaluation plans within and across sectors and levels at the national and community levels have not yet been harmonized. Without the coordinated development of evaluation, uneven and stalled progress will go unnoticed and opportunities to correct efforts or build on successes will be missed. Although the United States previously developed a nutrition monitoring plan (Briefel, 2006; Briefel and McDowell, 2012) and a surveillance plan for Healthy People 2020 exists (Green and Fielding, 2011), the nation does not yet have an evaluation plan for obesity prevention as recommended in the APOP report (IOM, 2012a). This chapter describes recommendations for a U.S. National Obesity Evaluation Plan that can be used as a resource and model for state and regional evaluations. This chapter includes summaries of current international and national evaluation plans; an outline of a National Obesity Evaluation Plan to evaluate strategies identified in the APOP report; recommendations to adapt this plan at the state and regional levels; and considerations for how community and local level data, which will be discussed in Chapters 7 and 8, can be incorporated to enhance and support the National Obesity Evaluation Plan. In addition, because the Committee was tasked to identify measurement ideas for The Weight of the Nation (TWOTN) campaign,1 this chapter discusses opportunities and challenges for evaluating this campaign within the National Obesity Evaluation Plan. 1  TheWeight of the Nation is a coordinated, multi-media, multi-organizational campaign designed to help create awareness, inform, and motivate action to slow, arrest, and reverse the trend of obesity across the United States. 134 Evaluating Obesity Prevention Efforts

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BOX 6-1 Addressing Health Inequalities as Part of a Systems Approach in the National Obesity Evaluation Plan As documented in Chapter 5, obesity-related disparities exist across various racial and ethnic groups and socially disadvantaged populations. Patterns of association among a multitude of factors, particularly those upstream that denote social advantage or disadvantage, may provide important insights for addressing health equity and obesity disparities. The ability to measure such factors is central to the characterization of patterns of association. Braveman et al. (2011) identify sociocultural and socioeconomic determinants, timing of exposure, and living and working conditions as central constructs to measure. As such, a National Obesity Evaluation Plan will need to include indicators to address these determinants. In addition to a national pattern of associations among these factors and health, a connection to state and community determinants will allow for comparison of these indicators at different levels, identification of emerging issues or trends that should be incorporated into the National Obesity Evaluation Plan, and relationships that address the multiple levels of this systems perspective. Chapters 1 and 2 focus primarily on “why” evaluation should be conducted. Chapters 3, 4, and 5 tackle “what” needs to be done and for “whom.” This chapter addresses the “how” of evaluation at the national level by proposing a concrete National Obesity Evaluation Plan, as well as recommendations for its implementation across multiple sectors (see Chapter 1), framed in a systems-level approach (see Chapter 9) that addresses health equity (see Chapter 5 and see Box 6-1). Relationship of NATIONAL Obesity EVALUATION PLAN to proposed Evaluation framework The Committee designed the evaluation framework offered in Chapter 3 (see Figure 3-1) to provide a logic model, including inputs, activities, outputs, outcomes, and impacts that can be easily applied to evaluation plans assuring timely and meaningful collection and analysis of data to inform and improve obesity prevention efforts at national, state, and community levels (Committee vision, Chapter 1). Aligning the National Obesity Evaluation Plan, as well as state- and community-level plans, with the evaluation framework provides context for the rationale and measurement components underlying the Committee’s recommendations (see Chapter 10). The National Obesity Evaluation Plan is outlined in Box 6-2. The plan was conceptualized to include an overarching purpose that is directly related to the strategies from the APOP report (IOM, 2012a) and the evaluation framework; a list of broad objectives that detail the steps that must be followed; and a list of more specific activities that result from operationalizing the objectives. The Committee understands that the activities, in particular, are ambitious and will likely be implemented over several years; however, to adequately determine the effectiveness of the APOP strategies and current efforts in obesity prevention, significant and bold changes in the current U.S. system for evaluation of progress in obesity prevention must be put into place. National Obesity Evaluation Plan 135

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BOX 6-2 Core Components and Activities of the National Plan for Evaluating Progress in Obesity Prevention Purpose: To evaluate progress at the national level in implementing strategies from the IOM Accelerating Progress in Obesity Prevention (APOP) report (IOM, 2012a) and in achieving intended impacts as described in the evaluation framework (#5 in Figure 3-1). Components: 1. Identify leadership, infrastructure, resources, priorities, and timeline for implementing the plan. 2. Identify current national efforts for evaluation, including indicators (Chapter 4), and incorporate them selectively into national monitoring, surveillance, and summative evaluation data systems that are respon- sive to the needs of data users. 3. Propose data and infrastructure to add to existing monitoring and surveillance systems to fill gaps and facilitate community obesity evaluation plans. 4. Propose additional assessment, monitoring, surveillance, and summative evaluation activities; new mea- sures; and innovative strategies to implement in the future. 5. Outline mechanisms for feedback to data users, assuring accessibility, privacy, and cost-efficiency. 6. Detail adaptations of the plan at the state level, with further applications at the regional level. Activities: 1. Designate a federal obesity evaluation task force/entity to oversee the implementation of the National Obesity Evaluation Plan and coordinate with relevant federal, state, local, and private-sector entities. a. Identify and obtain the infrastructure necessary for implementing the plan and coordinate with appro- priate partners. b. Ensure adequate benchmarks/goals, including a schedule for updates. c. Establish a process for prioritization, accountability, and adaptation of plan activities including an annual report to the agency responsible for leading the effort. d. Identify priorities and create an ongoing timeline for implementing the plan. i. Short-term objectives achievable within 1-3 years. ii. Intermediate-term objectives achievable within 3-5 years. iii. Long-term objectives achievable in 5 years or longer. 136 Evaluating Obesity Prevention Efforts

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2. Identify current national evaluation efforts, including indicators for monitoring and surveillance systems to minimize duplication, maximize use of data already being collected, and identify priorities to address evaluation gaps in a coordinated fashion. a. Use the indicator list (Chapter 4) as a starting point to identify a core set of indicators. b. Match indicators as much as possible for common measurement across jurisdictions. c. Examine existing links to the Leading Health Indicators and other recommendations as consistent with APOP. d. Promote use of common measures through the National Collaborative on Childhood Obesity Research (NCCOR) (see Chapter 5) to facilitate harmonization of data across data collection systems. e. Expand School Health Policies and Practices Study to include measures of additional settings such as worksite, child care centers, and schools on a rolling basis every 3 years rather than of current set- tings every 6 years. f. Expand National Health and Nutrition Examination Survey (NHANES) sampling, analyses, and/or reporting to address gaps in developmental levels of children birth to 1 year, 2 to 5 years, 6 to 10 years, 11 to 13 years, and 14 to 19 years. g. Expand NHANES to oversample populations that are underserved or at greater risk for obesity. h. Standardize currently collected data and planned systems, such as electronic health records, for data aggregation. i. Incorporate data from birth certificates, Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), Early Head Start, and Head Start into the National Obesity Evaluation Plan. j. Expand current monitoring and surveillance structures into existing data-collection systems at the national or state levels. 3. Develop new data-collection infrastructure or systems, indicators, and measures to address gaps identified as priorities in areas such as policy and environment, physical activity, child care centers, worksites, health plans, federally qualified health centers, and community health centers/WIC clinics. 4. Increase national and state capacity for assessment, monitoring, surveillance, and summative evaluation. a. Standardize and provide training on measurement protocols (e.g., body mass index, waist circumfer- ence) and data-collection methods. b. Provide technical support for data utilization, statistical analysis, and reporting. i. Assess the impact of the data loss that resulted from discontinuation of the Centers for Disease Control and Prevention’s Pediatric Nutrition Surveillance System and Pregnancy Nutrition Surveillance System (state- and county-level data) and provide ongoing technical assistance to states that use existing data. continued National Obesity Evaluation Plan 137

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BOX 6-2 Continued c. Create lists of recommended standardized tools and methods for measurement. i. Expand and maintain the NCCOR Surveillance System and Measures Registry. 5. Ensure that all relevant data systems include a mechanism for relevant and timely feedback to data users. a. Expand Health Indicators Warehouse and other interactive sources of federal-level data. b. Expand and maintain Community Commons. c. Develop additional “dashboards” and “federal report card” formats that can be interactive and display data in easily understood infographics and tables. 6. Ensure that evaluation plans in federally funded obesity-related grants and programs include common indicators and measures that can be aggregated across communities and inform the plan. 7. Encourage development and testing of alternative and emergent methods of collecting data, including a. Real-time access of data from community-based organizations, b. Capitalization on the “quantified-self” movement, and c. Use of new technologies and geospatial modeling. For a national evaluation plan, differing population needs demand inputs of varied data collection. Context is also varied, spanning urban to rural geographies and affluent to poorer communities, so a national evaluation plan must be broad, adaptable, and culturally sensitive to cover various environments, languages, contexts, and populations. Inputs also include objectives and goals that serve as evaluation benchmarks; they often link to national health goals, such as Healthy People 2020 (HHS, 2010b), and include specific populations (Green and Fielding, 2011). State objectives tend to be patterned after national obesity, diet, and physical activity objectives; many have been developed or adapted from the Healthy People 2020 template with Centers for Disease Control and Prevention (CDC) funding and guidance (CDC, 2012b). Development of an evaluation plan aligned with a core set of national-level indicators is one of the primary activities outlined in the evaluation framework. State-specific indicators can provide further con- text and focus on individual issues that are likely to arise in localized areas. Infrastructure development is necessary as well, and it can range from the broader and more complicated infrastructure at the national level to smaller and more limited infrastructures at the state level. Available funding, workforce capacity, political will, and the perceived need for obesity prevention can affect infrastructure for collecting, analyz- ing, and reporting data. 138 Evaluating Obesity Prevention Efforts

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The recommendations of the National Obesity Evaluation Plan outlined in this chapter represent one of the major outputs of the evaluation framework. The plan organizes designated indicators from Chapter 4, with comparisons and benchmarks for impact variables, using appropriate methodology and feedback opportunities to assess progress in obesity prevention. The recommendations and guidance for the evaluation can inform adaptation and implementation of the plan. With implementation of the plan, several outcomes can be realized. Capacity and infrastructure for evaluation at both national and state levels will improve, leading to increased numbers and complexity of monitoring, surveillance, and evaluation activities. As well, data gleaned from these efforts can be dissemi- nated back to stakeholders and consumers for use in informing decisions about resource allocation and intervention efforts. Implementation of the plan will provide data from various sectors to document progress in obesity prevention. Although a variety of impacts are important, for obesity prevention the impacts of the plan reflect a multi-level and multi-sector focus that targets various interventions through a lens of health equity and includes changes in both environments and behaviors, mirroring the guidelines provided in the APOP report (IOM, 2012a). National Obesity Evaluation PlanS International Examples Obesity is a worldwide problem, and, as such, world and regional organizations, as well as other c ­ ountries, have proposed monitoring, surveillance, and evaluation plans for obesity prevention and con- trol. To develop the National Obesity Evaluation Plan for the United States, the Committee examined international efforts as models to determine which components were applicable to the United States and consistent with APOP strategies (IOM, 2012a). Of particular interest were indicators or methodologies that could later be used across countries to facilitate cross-country comparisons. Comparing data from different countries can highlight innovative policy or programmatic efforts and outcomes and contribute to the body of evidence regarding effective obesity prevention strategies. A brief review of prominent international obesity plans follows. The World Health Organization (WHO), International Agency for Research on Cancer, the European Commission, and the Ensemble Prévenons l’Obésité Des Enfants (or EPODE, Together Let’s Prevent Childhood Obesity) European Network have produced plans for monitoring, surveillance, and evaluation of obesity prevention and control (Riboli et al., 2002; WHO, 2008). Single countries— Australia, the United Kingdom, and others—have documented obesity prevention evaluation plans (Australian Government Department of Health and Aging, 2010; WHO, 2007). In these countries, evalu- ation plans have built on existing national nutrition monitoring/surveillance systems and data infrastruc- tures, many of which are more thoroughly and universally linked across record systems in those countries than in the United States because of the national health systems in those countries. Many of these plans include goals consistent with several APOP strategies, making them useful models for informing the U.S. National Obesity Evaluation Plan and enabling comparisons of progress with other countries and regions of the world. The WHO has a framework that can be adapted by countries to evaluate the components of the WHO Global Strategy on Diet, Physical Activity and Health (DPAS) (WHO, 2008). DPAS, proposed in National Obesity Evaluation Plan 139

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2004, focuses on the worldwide increases in noncommunicable diseases as a result of poor dietary intake and activity levels (WHO, 2004). DPAS includes a strong emphasis on the role of government in provid- ing leadership in these efforts. It calls for development of national dietary and physical activity guidelines and policies, coordination of agricultural policies, educational and health literacy efforts, multi-sectorial policies for physical activity, school-based policies to promote healthful diet and activity, and preven- tion efforts through health care or health services (WHO, 2004). The related WHO evaluation strat- egy (WHO, 2008) also calls for a monitoring, surveillance, and evaluation plan. The WHO European Database on Nutrition, Obesity, and Physical Activity (WHO, 2011) contains information on national and subnational surveillance data, policies, and actions to implement policies. The WHO evaluation plan proposes that countries set up a process to ensure that monitoring, sur- veillance, and evaluation activities are included in all intervention plans, by identifying existing relevant activities and suitable partners, selecting appropriate indicators, and carrying out the monitoring, sur- veillance, and evaluation activities periodically in a consistent manner (WHO, 2008). The WHO recom- mends the development and tailoring of process, output, and outcome indicators by each country with consideration of national characteristics or culture, policy, settings, and available scientific evidence. The agency encourages evaluations of programs and initiatives that draw on existing monitoring and surveil- lance activities in each country (WHO, 2008). Key outcome indicators are grouped by periodicity/time scale, with short-, intermediate-, and long-term indicators. Indicators range from awareness of dietary and p ­ hysical activity goals in the short term to physiologic factors, and dietary and physical activity behaviors in the intermediate term. Long-term outcomes, referred to as “impacts” in Figure 3-1, relate to over- weight and obesity goals, as well as morbidity and mortality. The intent is that countries are encouraged to use these comprehensive strategic pillars to develop national evaluation plans with robust monitoring, surveillance, and evaluation components. Appendix F (Table F-1) presents other examples of international e ­ valuation plans and activities. Strengths and Weaknesses of the Current U.S. National Obesity Evaluation Advantages and Strengths of the Current U.S. Surveillance System for Obesity Prevention The current U.S. national surveillance systems for obesity and related risk factors have many advan- tages, including a historical record that provides tracking of key impact measures, validated and reliable measures, biologic measures, and sample sizes that provide population-level estimates for various sub- groups, focused on individual-level data. In addition, Healthy People 2020 (HHS, 2010b) and Physical Activity Guidelines for Americans (HHS, 2010a) provide a framework of objectives and key indicators that inform national evaluation efforts and influence the items available in the National Health and Nutrition Examination Survey (NHANES), National Health Interview Survey (NHIS), Behavioral Risk Factor Surveillance System (BRFSS), Youth Risk Behavior Surveillance System (YRBSS), and other sur- veillance systems. Although the majority of data are available at the national level, sampling of selected regions by the BRFSS—Selected Metropolitan/Micropolitan Area Risk Trends (SMART) allows the use and comparison of national, state, and some city/county variables at representative levels for selected communities. Several of these factors are also consistent with the WHO framework to monitor and evalu- ate obesity prevention efforts (WHO, 2004). Finally, the expanded use of technology has allowed for rapid collection and analysis of some types of data to provide tools that can potentially be replicated at 140 Evaluating Obesity Prevention Efforts

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other levels and could provide data on incidence of obesity and related outcome indicators, in addition to the usual prevalence estimates. Gaps and Weaknesses in Current National Obesity Surveillance The current national monitoring/surveillance system can track obesity prevention efforts and their effects, and it has several strengths as detailed above; however, gaps in the current system exist. These gaps include a lack of data to enable monitoring of key policy, systems, and environmental strategies that are highlighted in the APOP report (IOM, 2012a); a decentralized leadership with limited authority, responsibility, or support and coordination at the national level;2 a paucity of physical activity and envi- ronmental indicators to enable surveillance of nutrition and obesity measures; a lack of data for certain populations or child developmental levels; gaps by time period or region; a lack of measurement of the incidence of obesity; a lack of resources and infrastructure for surveillance and timely reporting of results; and a lack of data for use at the community level. Lack of monitoring of policy and environmental data.  To date, the majority of monitoring and program summative evaluation data have used individual-level measures, because those have been the focus of most intervention efforts, programs, and government recommendations in the past (Green et al., 1974; Marketing Economics Division, 1972; Wang and Ephross, 1970; Wang et al., 1972). The APOP report (IOM, 2012a), however, frames obesity prevention efforts ecologically in terms of policy, systems-level, and environmental approaches, which require new evaluation approaches and measures. In particular, comprehensive monitoring, surveillance, and summative evaluation systems are needed for all settings, including early child care, schools, worksites, and health care. These systems can be difficult to implement and maintain, mostly because of the lack of an overall national organizational structure and incentives for obesity prevention in these settings. Finally, databases and methods to track exposure to media messages about diet or physical activity are needed to monitor progress in improving the messaging environment (APOP Goal Area 3, IOM, 2012a). Lack of data for certain populations.  Many existing national monitoring and surveillance plans are designed to oversample various subgroups of the population, such as low-income persons and minorities, but data remain limited for some segments of the population, such as the homeless, and certain racial/ ethnic groups, such as Native Americans, Latino/Hispanic subgroups, and Asian Pacific Islander popula- tions (Koh et al., 2012; Wang and Beydoun, 2007). Special subnational studies offer the most economical way to cover these and other minority groups as part of a National Obesity Evaluation Plan, as outlined in Chapter 5. In addition to expanded coverage of population subgroups, improved geographic coverage is needed to provide obesity data at state and community levels. The CDC surveillance systems (e.g., BRFSS, YRBSS) provide data for participating states that are complementary to national data, but there is increasing inter- est in collecting state data to address local health and welfare concerns, as well as to collect data on state- 2  Includesbut not limited to efforts in the following federal agencies: Corporation for National and Community Service; Departments of Agriculture, Commerce, Defense, Education, Health and Human Services, Interior, Labor, Transportation, and Veteran Affairs; Domestic Policy Council; Environmental Protection Agency; Federal Trade Commission; General Services Administration; and Office of Management and Budget. National Obesity Evaluation Plan 141

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level policies and environments and enhanced sample sizes in selected local populations. For example, the California Health Interview Survey3 provides data on specific racial/ethnic populations such as Latinos living within California. Another example is the Lower Mississippi Delta Nutrition Intervention Research Initiative funded by U.S. Department of Agriculture (USDA), which uses evaluation and community partici- patory methods to assess diet and chronic disease in a three-state region (Ndirangu et al., 2010). Overlap of existing data collection efforts.  The current U.S. monitoring/surveillance efforts include some overlap of data collected by different monitoring/surveillance systems. For example, similar school policy and environmental measures are collected in School Health Policies and Practices Study (SHPPS), School Nutrition Dietary Assessment Survey (SNDA), and Bridging the Gap assessments. By coordinating efforts and having a designated task force/entity to oversee this process, duplication of activities could be mini- mized and resources could be better leveraged. Gaps in monitoring and surveillance by periodicity, setting, or region.  Although some systems for collec- tion of data about policies and environments exist, such as the SHPPS survey, the data are not collected at regular enough intervals to inform and provide adequate feedback on actions to prevent obesity or to improve the implementation of existing policies and interventions. In addition, with longer time periods between data collection, it is difficult to maintain consistent funding and infrastructure over time, resulting in duplication of effort and loss of institutional knowledge about the surveys. For example, SHPPS data are collected every 6 years, which is helpful for long-term trends but does not provide real-time data for deci- sion makers. The APOP report (IOM, 2012a) recommended that SHPPS data collection be adjusted to once every 2 years. Modifying that to include different settings such as worksite, child care centers and schools, a 3-year measurement period could be instituted. Data could be collected on a rolling basis with alternate surveys in different environments in different years so that, for example, schools could be surveyed one year, child care settings could be surveyed the following year, and worksites surveyed the third year. Lack of infrastructure at regional and state levels.  The current national monitoring and surveillance sys- tems have evolved to use sophisticated and systematic measures and technology infrastructure to support data collection, cleaning, analysis, and reporting, as well as specialized knowledge and technical expertise. Often, the infrastructure or capacity for this type of data collection is lacking or not as well developed at the regional or state levels; this capacity is also lacking at local health departments as addressed in Chapters 7 and 8. In addition, although the knowledge and expertise for sampling methods and mea- surement theory may exist in the state, this type of expertise might not be found at the state health department or in state government. To increase workforce capacity for monitoring, surveillance, and summative evaluation, it is essential to incorporate elements of public health and surveillance into health ­ rofessionals’ education (Drehobl et al., 2012). p Lack of standard indicators and measures.  Although relatively standard methods of collecting individual- level data are available and frequently used (e.g., body mass index), there is less standardization of policy, systems, and environmental indicators and measures. Recently, efforts to develop measures for policies 3  See http://healthpolicy.ucla.edu/Pages/Home.aspx (accessed November 11, 2013). 142 Evaluating Obesity Prevention Efforts

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and environments for food and physical activity have been spearheaded primarily by the Robert Wood Johnson Foundation through the Bridging the Gap, Active Living Research, and Healthy Eating Research programs (Ottoson et al., 2009; RWJF, 2013a,b; University of Illinois at Chicago, 2013a). Many of these measures have been evaluated for psychometric properties such as validity and reliability and are now being used consistently in research studies. Along with the physical and policy environment, the behav- ioral environment should also be assessed, including social norms for diet, physical activity, and obesity. Components and Guidance for Implementing the National Obesity Evaluation Plan The National Obesity Evaluation Plan for assessing progress in obesity prevention builds on the cur- rent strengths and infrastructure of the existing monitoring and surveillance systems in the United States, including Healthy People 2020 (HHS, 2010b), but it proposes the incorporation of new infrastructure (i.e., surveys and sources of data) to measure policy, systems, and environmental indicators (see Box 6-2), as well as integration with international efforts. The plan includes many of the proposed methods and indicators outlined in the WHO Global Strategy on Diet, Physical Activity and Health: A Framework to Monitor and Evaluate Implementation (WHO, 2008) and thus will be consistent with similar evaluation efforts internationally. Insofar as APOP strategies (IOM, 2012a) focus largely on policy, systems, and environmental approaches, while existing assessment, monitoring, surveillance, and summative evalua- tion efforts primarily focus on individual-level outcomes, the plan needs to align the newer intervention approaches with appropriate indicators. Components of the plan are tied to proposed activities, including identification of overall leader- ship, infrastructure, resources, and timeline for the plan; identification of current federal efforts and data gaps; proposals for additional and new measures, infrastructure, and data collection systems to address these gaps; mechanisms for feedback to data users; and adaptations of the plan to state and regional applications (see summary Table 6-1). Plan activities need to prioritize and leverage existing resources to maximize efficiency of data collection, as well as to avoid duplication of efforts. Several of the proposed activities could be implemented relatively easily and with little cost as, for example, new questionnaire items added to the BRFSS or the YRBSS. Other recommendations, such as decreasing the time period for SHPPS from 6 years to 3 years are relatively expensive, and therefore must be balanced with other priori- ties. Other considerations when prioritizing recommendations include • Which sectors to target with priority? Are the appropriate stakeholders and potential users involved in setting these priorities and providing feedback (see Chapter 2)? • What is the appropriate time frame for each measurement? Does this fit within the time frame needed to evaluate obesity prevention efforts? • How precise do the measures for the indicator need to be? Can a survey tool be used, or is a more objective or precise measure required? • Which populations need to be measured? Do survey planners need to oversample certain racial and ethnic groups, such as pregnant women or Native American populations? To be relevant, as well as to address the current status of APOP strategies (IOM, 2012a), evaluation activities for the National Obesity Evaluation Plan should follow the steps outlined in Chapter 8 (see National Obesity Evaluation Plan 143

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Guidance for State Obesity Evaluation Plans In general, evaluation of progress in obesity prevention at the state level ideally would be modeled after the National Obesity Evaluation Plan (see Box 6-2), which would allow states to compare state-level data to national data and guidelines (e.g., state adult obesity prevalence compared to the national adult obesity prevalence). Although patterning state evaluation plans after the National Obesity Evaluation Plan may be an appropriate and efficient first step, state monitoring/surveillance systems will likely need to include questions that address specific indicators or issues in specific state priority populations. Because states tend to be more nimble than the federal systems, and because states often have distinct populations that require changes in measurement protocols or instruments, it is anticipated that exemplars at the state level might serve as a resource or “pilot” for addressing gaps at the federal level identified in the National Obesity Evaluation Plan. These new protocols or instruments can provide new indicators or measurement techniques that can later be adapted for national monitoring/surveillance systems. As with the National Obesity Evaluation Plan, states would ideally identify an obesity task force that would reside in the state health department and report directly to the state commissioner of health, or even to the governor as a multi-agency state task force. This task force needs to be comprised of state department heads and stakeholders inclusive of all geographic areas of the state. State health goals would provide benchmarks and guidelines for indicators, although most state obesity plans likely will model these after federal recommendations. Detailing a process to establish priorities and a timeline for imple- mentation would further strengthen the plan. An assessment of current monitoring, surveillance, and other summative evaluation efforts at the state level would be the next step in the State Obesity Evaluation Plan; this is expected to be a less inten- sive undertaking than detailed in the National Obesity Evaluation Plan. While conducting an inventory of state evaluation methods and systems, it is important to determine if state-level indicators are consistent with those at the federal level (see Table 6-4). Thus, harmonization of indicators and data collection sys- tems would include comparisons with both federal and state measures and infrastructure. Some states will need to develop capacity to implement a State Obesity Evaluation Plan. In addi- tion to consistent funding to support evaluation activities, states will need to cultivate a workforce with expertise in sampling, statistical analysis, and public health. Partnering with local state universities may be a potential solution for addressing workforce needs. In addition, new questionnaires and survey items may need to be developed to address special state populations, and technical assistance may be required as well. CDC has traditionally provided technical assistance to states for surveillance and other summative evaluation efforts through the Division of Adolescent and School Health, Prevention Research Centers, the BRFSS, and the YRBSS. An important part of the State Obesity Evaluation Plan is the timely feedback to state stake­ olders. h Again, the resources at the state health agency, as well as state mandates, may determine how quickly data can be collected, analyzed, and disseminated. At the state level, newer methods such as crowd s ­ ourcing or individual data collection might be easier to implement than at a national level and may pro- vide local data; however, for this to be viable, it will be necessary to develop more “off the shelf” utility products that can be easily implemented with more limited staff and resources. One limitation of state-level data is the inconsistency of monitoring/surveillance activities due to fluctuations in state budgets and unfunded mandates. For example, measurements that are obtained 172 Evaluating Obesity Prevention Efforts

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through schools, such as Fitnessgram®,19 can be difficult to sustain consistently over time without alloca- tion of resources. Examples of Regional Obesity Evaluation Plans Regional efforts related to evaluating progress in obesity prevention may be defined as those that are applied to a discrete area of common interest, such as the service area of a health plan, a geographic area across multiple states where an employer has worksites or a stream of migrant workers travel, or aggregations of counties with population characteristics in common (e.g., the Appalachian region across North Carolina, West Virginia, and Pennsylvania). Regions may not be confined by state borders or geography and may be defined by industry market interest, by health disparities, or by other health- or disease-­ elated factors. As a result, evaluation efforts for a regional audience may differ from national- or r state-specific efforts. One efficient and relatively low-cost method of obtaining good quality data on obesity prevention efforts and outcomes is through health plans. A health plan is likely to be interested in knowing the prev- alence or incidence of obesity among its members and whether they vary in obesity-related care by sub- regions across its service area, by care delivery systems among its contracted network, or even by clinic where members receive their care. Whereas a health plan may be informed by state-specific data, such data may not be specific to its membership. Plan-specific data may come from a variety of sources, includ- ing EHRs, clinical screenings, health impact assessments, the National Committee for Quality Assurance (NCQA) Healthcare Effectiveness Data and Information Set (HEDIS), and member surveys. For example, HEDIS consists of 75 measures across 8 domains of care and is used by more than 90 percent of U.S. health plans; these data could be useful for obesity prevention efforts if aggregated across regions (NCQA, 2013). The America’s Health Insurance Plans provides updates on obesity for its member plans and includes recommendations on addressing obesity (America’s Health Insurance Plans, 2008). Similarly, the Alliance of Community Health Plans provides its member plans with obesity-related updates and applica- tions (ACHP, 2013). BMI data can be efficiently collected via EHR and, when collected this way, have been shown to be as accurate as other population-based surveys, such as the BRFSS (Arterburn et al., 2010). Health plans also use membership surveys to document a variety of health- and care-related variables, including obe- sity, as well as the relationship of obesity to health care costs, disease diagnoses, and pharmacy-related concerns (Pronk, 2003). Often, these data are publicly displayed on health plans’ websites (e.g., see HealthPartners, 2011). NCQA, through HEDIS, reports on obesity-related metrics (NCQA, 2012). Also, health assessment may be used to monitor obesity-related data on subgroups of health plan members. Additional information related to health plans and information that can be used to evaluate obesity pre- vention interventions can be found in Chapter 2. In essence, with coordination, health plans can serve as efficient and relatively low-cost regional surveillance data sources. In the context of the worksite setting, employers increasingly use workplace screening programs to document and monitor BMI and obesity, as well as related health risks (Framer and Chikamoto, 2008; Goetzel and Ozminkowski, 2008). In addition, obesity-related claims may be used to gain a better under- 19  See http://www.cde.ca.gov/ta/tg/pf (accessed November 11, 2013). National Obesity Evaluation Plan 173

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standing of the costs and disease burden associated with excess weight (Colditz, 1992; Finkelstein et al., 2009), locally or regionally. sUMMARY Implementation of a National Obesity Evaluation Plan to assess the APOP strategies would enhance the ability of the United States to demonstrate progress in obesity prevention efforts, provide guidance on gaps in the extant programs and policies, and redirect use of resources. Elements of the National Obesity Evaluation Plan were developed to maximize existing monitoring/surveillance systems and incorporate metrics that are similar to those in other plans, such as the WHO framework. Objectives of the plan include the appointment of a federal obesity evaluation task force with accountability to coordinate a monitoring, surveillance, and summative evaluation system with rapid feedback and utilization by stake- holders, increased resources for monitoring/surveillance and summative evaluation, and creation of new and innovative methods to take advantage of current technological capacity. Settings that were identified as key areas of focus in the APOP report, such as worksites and child care centers, should be included in current monitoring/surveillance systems. Physical activity measures should be added or strengthened in the U.S. monitoring/surveillance systems, and new measures to assess social and built environments should be included as well. Barriers to the implementation of the plan include costs, competing priorities, and the efforts involved with coordinating the separate components of the evaluation systems into a harmonized whole. Addressing the barriers will require that both decision makers and evaluation users are aware of the con- sequences of obesity, as well as acknowledgment of the role of evaluation in the assessment and develop- ment of obesity prevention interventions. Implementation of the State Obesity Evaluation Plans will need to be aligned with the National Obesity Evaluation Plan to allow for comparability; however, state-level evaluation activities should be flexible enough to adapt to unique populations and state characteristics. Regional evaluations can take advantage of new initiatives to coordinate electronic health data to provide estimates for specific groups that extend across states. Implementation of a National Obesity Evaluation Plan is an essential part of the implementation of recommendations in the APOP report. A coordinated monitoring/surveillance system would greatly enhance the ability of the United States to track intervention efforts across different environments, as well as to determine if our current efforts are preventing obesity or if a different direction is warranted. Chapter 10 provides seven recommendations (and a set of potential actions and actors) to support the implementation of the components of the National Obesity Evaluation Plan. referencES ACHP (Alliance of Community Health Plans). 2013. Pediatric obesity: Addressing a national challenge at a local level. http://www.achp.org/for-the-public/achp-plans-are-innovating-to-achieve-the-industrys-triple-aim/­ pediatric-obesity-addressing-a-national-challenge-at-a-local-level (accessed April 4, 2013). America’s Health Insurance Plans. 2008. Facing the challenge of unhealthy weight: Recommendations for the health care community. Washington, DC: America’s Health Insurance Plans. 174 Evaluating Obesity Prevention Efforts

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