1

Introduction

Few dispute obesity is a significant and growing public health issue, but no one has identified a single or simple solution. The overweight and obesity1 epidemic cannot await the completion of all the rigorous research studies that would lend greater certainty to the efficacy of interventions and their applicability to varied populations. Instead, some carefully selected interventions can and must proceed on a trial-and-error basis to build a responsible response to the epidemic in an evidence-informed and theory-inspired manner. Evaluation builds on the body of science aimed at better understanding the complex biology of obesity, and on efficacy-tested interventions to combat the epidemic. Evaluation also recognizes that even the best scientific evidence of efficacy does not guarantee that an intervention will be effective when applied in specific populations and within community contexts.

Evaluation offers evidence on the need for, and the quality and effectiveness of, a range of interventions aimed at preventing obesity (interventions include policies, programs, services, and environmental changes). It can offer (1) assessment of the distribution of the problem and need for intervention; (2) monitoring of interventions, a source of quality assurance on how well those responsible for implementing programs or enforcing policies are performing their functions; (3) through surveillance, a long-term assurance that the implementation of interventions is achieving intended outcomes or impact; and (4) summative evaluation providing judgment of a program’s or policy’s merit and worth. Evaluation is central and essential to a “learning organization,” to responsible legislators in amending or changing policies, to advocates in making their case, and to administrators in their stewardship of resources and programs.

PURPOSE OF THE REPORT

The purpose of this report, developed by the Institute of Medicine’s (IOM’s) Committee on Evaluating Progress of Obesity Prevention efforts, is to develop a concise and actionable plan for measuring progress in obesity prevention efforts for the nation and adaptable guidelines for community assessments and evaluation. The Committee was tasked to

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1Overweight and obesity are defined in Appendix B.



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1 Introduction F ew dispute obesity is a significant and growing public health issue, but no one has identified a single or simple solution. The overweight and obesity1 epidemic cannot await the completion of all the rigorous research studies that would lend greater certainty to the efficacy of interventions and their applicability to varied populations. Instead, some carefully selected interventions can and must proceed on a trial-and- error basis to build a responsible response to the epidemic in an evidence-informed and theory-inspired manner. Evaluation builds on the body of science aimed at better understanding the complex biology of obesity, and on efficacy-tested interventions to combat the epidemic. Evaluation also recognizes that even the best scientific evidence of efficacy does not guarantee that an intervention will be effective when applied in specific populations and within community contexts. Evaluation offers evidence on the need for, and the quality and effectiveness of, a range of interven- tions aimed at preventing obesity (interventions include policies, programs, services, and environmental ­ changes). It can offer (1) assessment of the distribution of the problem and need for intervention; (2) monitori­ng of interventions, a source of quality assurance on how well those responsible for imple- menting programs or enforcing policies are performing their functions; (3) through surveillance, a long- term assurance that the implementation of interventions is achieving intended outcomes or impact; and (4) summative evaluation providing judgment of a program’s or policy’s merit and worth. Evaluation is central and essential to a “learning organization,” to responsible legislators in amending or changing policies, to advocates in making their case, and to administrators in their stewardship of resources and programs. Purpose of the report The purpose of this report, developed by the Institute of Medicine’s (IOM’s) Committee on Evaluating Progress of Obesity Prevention efforts, is to develop a concise and actionable plan for measur- ing progress in obesity prevention efforts for the nation and adaptable guidelines for community assess- ments and evaluation. The Committee was tasked to 1  Overweight and obesity are defined in Appendix B. 15

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1. draw on the recommendations and recommended indicators of progress from the preceding IOM Committee and report Accelerating Progress in Obesity Prevention: Solving the Weight of the Nation (APOP); consider currently used and new tools and metrics (e.g., trend analysis, community/local measures) to measure progress; and develop a plan for a national-level evalua- tion of obesity prevention efforts by sector and, if appropriate, across sectors; 2. develop a community-level evaluation plan that adds detail and support to the national-level evaluation plan; and 3. identify measurement ideas that can determine the specific impact of the Home Box Office (HBO)/IOM campaign The Weight of the Nation (TWOTN). The audience for the report includes decision makers, community members, researchers, and evalua- tors at all levels and across all sectors. The report’s recommendations are not expected to be implemented or even relevant to every level of evaluation from community and organizational to national, but report users can build on available monitoring and surveillance data and evaluations to aggregate up to com- munity and even state and national evaluations of specific components of obesity control efforts, and they draw on the Committee’s recommended resources to strengthen their capacity for evaluation. This chapter sets the stage by articulating the Committee’s vision for evaluating progress of obesity prevention efforts at national, state, and community levels, and introducing a framework for evaluation. The chapter then describes how the Committee approached its task by (1) providing an overview of the needs of important users of evaluation, (2) describing the scope and use of existing objectives and strate- gies (as defined by its task), and (3) reviewing the current context of surveillance and summative evalua- tion. This chapter offers a brief introduction and background to the Committee’s task and how it will be particularly relevant and useful to evaluation users, helping to establish an infrastructure for monitoring progress of obesity prevention efforts at national, state, and community levels. Much of this report’s guidance for evaluation plans may seem like generic methodological con- vention to the research-minded reader, so it is helpful to describe some ways in which the evaluation of progress in obesity prevention is similar to, and different from, evaluation of other prevention efforts. The fields of evaluation, policy analysis, surveillance, and community health assessment are hardly new, and this background knowledge contributed greatly to the Committee’s ability to anticipate issues, relate them to other prevention experience, and where necessary, differentiate the evaluation of obesity prevention from that experience. Evaluating Obesity Prevention compared to other prevention efforts The prevention field generally, and obesity prevention in particular, need to engage in surveillance of diseases and related conditions and assess the relative importance and trends in prevalence of factors­ associated with diseases and related conditions (see Chapters 3 through 8). In evaluating interventions, prevention efforts need to focus not only on implementation and outcomes but also on the reach of inter- ventions—their ability to influence large numbers of people to achieve population-level benefits (Gaglio and Glasgow, 2012; Glasgow et al., 1999; Green and Glasgow, 2006). The ecological model of prevention identifies many potential influences on health, and evaluation permits prevention practitioners to select the most powerful levers for change among the multiple ecological levels. National monitoring of preven- 16 Evaluating Obesity Prevention Efforts

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tion efforts needs to include some key indicators of these powerful levers at various levels of the ecologi- cal model, including the whole-systems level. Prevention of obesity offers a case in point, as noted in the very first IOM report on the subject (IOM, 2004). There is a growing realization for obesity prevention, as in the case of controlling tobacco and other drugs (Eriksen, 2004; Mercer et al., 2010), that policy and environmental approaches offer powerful levers for change. As discovered in these other areas, how- ever, it is difficult to use the most rigorous experimental designs in evaluating policy and environmental approaches. Evaluation of obesity prevention is on track to develop and adapt quasi-experimental meth- ods with enough rigor to reduce uncertainty about what works. However, given the stage of development of obesity prevention and the wide range of potential levers for change, evaluation faces some challenges that distinguish it from other prevention efforts. At the time of this Committee’s deliberations, it was still uncertain which factors can provide the most powerful levers, and the range of potential levers related to nutrition and physical activity is much greater than one would find even in complex situations such as HIV prevention or tobacco control. The range of factors is prob- lematic at the national level, but it is especially challenging at the community level. Complex situations require a much better understanding of the community context of obesity prevention. Although community context is essential to understand in other prevention efforts, it is even more important for obesity preven- tion efforts because the risk factors related to eating and activity affect everyone. This fact induces consid- erably more variation in community evaluations than in these other areas. It is imperative that obesity pre- vention narrow the range of possibilities. Two strategies to do so are outlined in Chapter 8: a strategy that screens and assesses the “evaluability” of many possible approaches before evaluating them and a strategy that investigates the “dose” of the intervention: intensity, duration, and reach into the target population. Current context for Evaluating obesity efforts As described in the prior section, much remains to be known about the determinants of obesity and the efficacy of interventions to reduce its incidence, prevalence, and consequences. The epidemic of overweight and obesity, however, demands action in the relative absence of (1) completed and compiled basic science on causal mechanisms and (2) controlled trials of interventions in representative popula- tions. Many of the program and policy interventions needed to confront the epidemic successfully on a population scale will not lend themselves to the full battery of experimental controls. Randomized con- trolled trials are ideal, but the ideal is not always possible nor may it answer questions being asked by decision makers interested in obesity prevention (Casazza and Allison, 2012; IOM, 2010a; Majumdar and Soumerai, 2009; Mercer et al., 2007; Rosen et al., 2006). The alternative is to take advantage of the inno- vative “natural experiments” that are being conducted nationally and locally. For example, New York City’s requirement of menu labeling in restaurants was a natural experiment, insofar as there was limited evidence that menu labeling would reduce calorie consumption. Yet this intervention offered an opportu- nity to test whether the requirement would have that effect. The evidence has since been mixed (Morrison et al., 2011), but the example illustrates the opportunity to test innovative interventions through sum- mative evaluation of field trials. State and district policies on competitive foods and beverages in schools (foods that “compete” with the school breakfast and lunch) have contributed to changing the school food environment in which the policies are implemented and will soon lead to uniform federal standards. Evaluations of the natural experiments of mass media campaigns, state and community policy initiatives, Introduction 17

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and programs in communities and organizations become sources of evidence for national and state initia- tives and models to be emulated in other communities and organizations if and when these natural experi- ments are evaluated with sufficient attention to a common framework and the comparable indicators s ­ uggested in this report. The APOP report (IOM, 2012a) makes using “natural experiments” as the main source of evalu- ation all the more compelling. The APOP report, to which this report is sequenced, framed obesity pre- vention by targeting policies, systems, and environments, rather than emphasizing changes in individual behavior, as many previous recommendations and published evaluations had done. Actions through such policies, systems, and environments are under way across the country in multiple forms, and surveillance systems exist to compare their effects over time and between jurisdictions. Much of what this report rec- ommends, then, is a more systematic application of these natural experiments to bring their results to scale and to the aid of states, communities, and organizations. This report is about how all societal sectors and levels can increase the likelihood that adopted obesity prevention interventions will be (1) matched to the assessed needs of populations, (2) monitored for their progress in adopting, implementing, and maintaining tested interventions, (3) evaluated in light of program/policy objectives, and (4) widely disseminated. The use of existing surveillance systems to maximize comparability of results across interventions, populations, and jurisdictions has provided much of the inspiration and role modeling of promising practices from one setting to another, and it can con- tinue to expand the reach of such interventions with the addition of recommended indicators of need and effectiveness. “Promising practices” have taken on new meaning in obesity control as the relative paucity and dubious representativeness, time intensiveness, or applicability of rigorously tested practices have forced national organizations and communities to innovate and apply ideas from public health successes and community projects (Brennan et al., 2011). The evaluation results of those public health successes (e.g., the National High Blood Pressure Education Program, the National Cholesterol Education Program, and tobacco control) and community projects, however, might not be applicable to the varied obesogenic circumstances of communities of varied ethnicity, resources, and socioeconomic conditions (Green and Glasgow, 2006). Evaluation of promising interventions, then, becomes more important for each commu- nity to test the intervention’s applicability there, and then cumulatively important for its broader applica- bility or adaptability across a wider variety of communities. A Note on Terminology In the literature, terms such as assessment, surveillance, monitoring, and evaluation are often used interchangeably or with meanings that vary among professions, disciplines, and settings. In this report the Committee uses these terms as described in Box 1-1, which may mean that the Committee’s usage in this report will sometimes not match the usage elsewhere. In this report, the Committee uses the term evaluation to refer to combinations or culmination of all four of these functions from needs to processes to ­ utcomes. The Committee uses the term summative evaluation, as in the evaluation literature where a o distinction is needed, to refer to the addition of experimental or quasi-experimental design features that provide greater certainty that the outcomes or impact can be attributed to the interventions. All of these forms of evaluation can apply to any combination of programs or components of programs, systems, 18 Evaluating Obesity Prevention Efforts

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BOX 1-1 A Note on Terminology • Assessment is an effort to use data on the community or other jurisdiction to characterize the prob- lem, its distribution, and efforts to address it. • Monitoring is the tracking of the implementation of interventions* compared to standards of performance.  • Surveillance is the ongoing systematic collection, analysis, and interpretation of data tracked over time to detect patterns, disparities, and changes that may be associated with interventions or other causes. • Summative Evaluation is the effort to detect changes in output, outcomes, and impacts associated with interventions and to attribute those changes to the interventions. • Evaluation refers to all four or various combinations of these functions (assessment, monitoring, sur- veillance, and summative evaluation). * In this report, interventions refer to programs, systems, policies, environmental changes, services, products, or any combina- tion of these multifaceted initiatives. p ­ olicies, environmental changes, services, and products. The Committee will refer to these objects of eval- uation collectively and in their various combinations as interventions. Vision Several IOM committees have given prominence in their reports to the importance and challenges of evaluating and measuring the progress of obesity prevention in terms of (1) assessment and monitor- ing of progress in implementing efforts and actions (interventions) to prevent obesity and (2) surveillance of changes and summative evaluation of progress in obesity control as a result of those interventions. For example, the 2004 IOM report Preventing Childhood Obesity: Health in the Balance grappled with the use of body mass index as the most common measure of overweight and obesity and evaluation of out- comes in obesity prevention efforts (IOM, 2004). It also addressed the growing expectation for commu- nity engagement in participatory studies, funding issues, and various design issues. In 2007, IOM released Progress in Preventing Childhood Obesity: How Do We Measure Up? That report concluded “evaluation serves to foster collective learning, accountability, responsibility, and cost-effectiveness to guide improve- ments in . . . obesity prevention policies and programs,” and it identified surveillance, monitoring, and research as fundamental components of these evaluation efforts (IOM, 2007, p. 8). The Committee refers the reader to previous reports, especially those on the linkage of research and summative evalua- Introduction 19

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tion (IOM, 1997), issues of cost, cost-effectiveness, and cost-benefit in community evaluation, and the weighing of trade-offs between benefits and harms of interventions (IOM, 2012b). The 2010 IOM report Bridging the Evidence Gap in Obesity Prevention: A Framework to Inform Decision Making addressed the need for development and integration of various sources of evidence and offered a framework for locating, assessing, and applying evidence to guide decision making (IOM, 2010a). This report builds on these other reports to offer an evaluation framework depicting resources, inputs, strategies, actions, and a range of outcomes important to prevention, all amenable to documentation, measurement, and evaluation (see Figure 1-1). As did previous committees, this Committee stresses the necessity of engaging multiple sectors and stakeholders in evaluations to assess and stimulate progress in obesity prevention over the short, intermediate, and long terms. To provide a vision of how and where this report should begin and where it should lead, the Committee developed a graphic representation, or framework, of the scope of inputs or people, resources, activities, outputs, outcomes, and, ultimately, impacts, that would need to be encompassed by the cumu- lative evaluation efforts, if not the individual strategies and methods of each project applying the recom- 1. Inputs • User/Stakeholder Needs • Existing Objectives Strategies • Context for Evaluation a • Guiding Principles for Evaluation a • Resources 5. Intended Impacts/ Vision: Assure timely and 2. Activities Improvements meaningful collection • Partnerships, Environments, Policies, and analysis of data and • Identify Indicators/Measures of Success Behaviors, Norms information to inform • Develop Evaluation a Plans and • Energy Expenditure/Intake and improve obesity Infrastructure • Overweight/Obesity prevention efforts at • Develop Resources for Training, Technical Assistance, and Dissemination • Population Health and Well-Being; Equity national, state, and community levels. 4. Outcomes 3. Outputs • Short-term: Improved Evaluationa Capacity and Training • Core Indicators and Measures • Intermediate-term: Increased • Recommendations and Guidance Evaluationa Activities • Support for Implementation • Long-term: Enhanced Data Use FIGURE 1-1  Framework for evaluating progress of obesity prevention efforts. a Evaluation refers to assessment, monitoring, surveillance, and summative evaluation activities. Figure 1-1.eps 20 Evaluating Obesity Prevention Efforts

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mendations (see Figure 1-1). The Committee aims to assure timely and meaningful collection and analysis of data to inform and improve obesity prevention efforts at national, state, and community levels. This framework addresses the full spectrum of resources or inputs to consider, activities to undertake, and the expected outputs, outcomes, and impacts that would result in fully realizing this vision. As such, the framework seeks to inform a systems perspective on the full range of influences on obesity and their rela- tionships to each other. The Committee used this framework to inform its approach to developing the national, state, and community obesity evaluation planning and measurement ideas and recommenda- tions. This framework and its components are fully described in Chapter 3. The Committee approached its tasks by searching for methods and indicators that would contribute to a model of evaluation that emphasizes its value as a professional or community learning tool to not only improve efforts, but also to prove their generalizable effectiveness (e.g., Green et al., 2009; Kottke et al., 2008). The Committee framed the evaluation not as an event, but as a continuous process of assessing community needs, plan- ning services, programs or policies, and environmental changes, and monitoring their implementation and summatively evaluating their effectiveness. Users of Evaluation Detailed in Chapter 2, key audiences for the report’s recommended plans and indicators are deci- sion ­ makers, community members, researchers, and evaluators at all levels and across all sectors, and the organizations that mandate or fund them. The Committee consisted of representatives from many of these stakeholders, and it reached out to representatives of other “end users” of this report’s recommendations to understand their needs and expected applications of evaluation ideas and measures. These consulta- tions included representatives from the Centers for Disease Control and Prevention (CDC) and National Institutes of Health (NIH), the main federal funders of evaluation of obesity prevention and the research that informs it, and agencies that need evaluation to accomplish their missions and objectives related to obesity prevention. existing objectives and strategies of Obesity prevention efforts The most recent among the several IOM obesity committee reports, referred to in this report as the APOP report (IOM, 2012a), supported the growing consensus of public health science and practice experts that environmental and policy strategies hold the most promise to accelerate progress in prevent- ing obesity over the next decade. Unlike the more central role of clinical and pharmaceutical strategies central to the National High Blood Pressure and National Cholesterol Control programs, the 20 APOP strategies were organized around five environments: 1. the physical activity environment, which includes the aspects of the physical and built environ- ment2 as well as norms and processes that increase access to, opportunities for, and social rein- forcement of activity and decrease barriers to engaging in physical activity; 2  Aspects related to the physical and built environment include transportation infrastructure, land use patterns, and urban design. Introduction 21

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2. the food and beverage environment, which seeks to increase the availability, attractiveness, and affordability of healthful foods and make unhealthful foods less available, attractive, and affordable; 3. the message environment that encompasses media and marketing that often promotes unhealth- ful foods and sedentary lifestyles but can be harnessed to counter those messages and promote healthful food and active lifestyles; 4. the health care and worksite environments in which promotion of healthful foods and physical activity can be arranged and promotion of unhealthful foods and sedentary lifestyles discour- aged, with referrals of patients or employees to existing community resources for support and guidance; and 5. the school environment as a hub of health promotion, given the daily hours spent there by chil- dren and youth, with potential for incorporating opportunities for healthful food and physical activity as well as health education and promotion, as well as for reducing access to unhealthful foods and sedentary lifestyles.3 Table 1-1 itemizes the specific APOP strategies by major level or sector for action, for which this report’s recommended obesity plans and supporting recommended actions are intended to apply. The APOP report supported the inclusion of these strategies using the best available evidence and implementation research. The APOP report stressed that the recommended strategies identified in the five key environments are interrelated and their collective implementation would have the most promise to accelerate obesity prevention over the next decade. Importantly, the report declared that successful implementation of the strategies will require engagement across all levels and sectors of society and leadership. This systems approach to obesity prevention, featured in Chapter 9 of this report, would coordinate the messages and environmental changes across multiple sectors and levels to provide maximum impact with minimal resources. The APOP report also identified extant and promising “indicators of progress” that could be mea- sured and analyzed to assess the impact of the APOP strategies. The APOP committee stressed that “it will be essential to monitor and track progress in the implementation” of the most promising strategies, “as well as to conduct sustained research on the magnitude and nature of their impact” (IOM, 2012a, p. 9). This Committee emphasized conclusions from prior reports that, although each strategy has the potential to accelerate progress, the system of large-scale transformative approaches that they recom­ mended will be successful only if all stakeholders commit to a sustained effort in implementation and evaluation of these strategies. the weight of the Nation Campaign Concurrent with the publication of the APOP report, HBO’s documentary film division and the IOM launched a coordinated, multi-media, multi-organizational campaign called TWOTN in May 2012. Presented in association with CDC and NIH, and in partnership with the Michael & Susan Dell Foundation and Kaiser Permanente, the campaign was designed to help create awareness, inform, and motivate action to slow, arrest, and reverse the trend of obesity across the country. The campaign includes 3  Strategies related to child care fall under physical activity, food and beverage, worksite, and health care environments. 22 Evaluating Obesity Prevention Efforts

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TABLE 1-1  Accelerating Progress in Obesity Prevention Report Recommended Policy and Environmental Strategies by Level or Sector of Action Major Levels Accelerating Progress in Obesity Prevention Report Recommended Strategies (Sectors) of Action (abbreviated topic version)* Systems level • Development, implementation, and coordination of common messages, processes, and strategies National • Physical education and physical activity in schools (public sector) • Physical activity in child care centers • Science and practice of physical activity • Sugar-sweetened beverages • Nutritional standards for all food and beverages • U.S. agriculture policy and research • Social marketing program • Food and beverage marketing standards for children • Nutrition labeling system • Nutrition education policies • Food literacy in schools • Weight gain and breastfeeding • School food and beverage standards State • Physical education and physical activity in schools (public sector) • Physical activity in child care centers • Science and practice of physical activity • Sugar-sweetened beverages • Nutritional standards for all food and beverages • Food and beverage retailing and distribution policies • Food literacy in schools Community • Enhancing the physical and built environments (citizens and civic • Physical activity-related community programs organization) • Sugar-sweetened beverages • Nutritional standards for all food and beverages • Food and beverage retailing and distribution policies • Social marketing program • Weight gain and breastfeeding Schools • Physical education and physical activity in schools (public sector) • Physical activity in child care centers • Sugar-sweetened beverages • Nutritional standards for all food and beverages • Food literacy in schools • School food and beverage standards Worksite • Sugar-sweetened beverages • Coverage of access to and incentives for obesity prevention, screening, diagnosis, and treatment • Healthy living and active living at work • Weight gain and breastfeeding continued Introduction 23

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TABLE 1-1  Continued Major Levels Accelerating Progress in Obesity Prevention Report Recommended Strategies (Sectors) of Action (abbreviated topic version)* Health care • Sugar-sweetened beverages • Nutritional standards for all food and beverages • Health care and advocacy • Coverage of access to and incentives for obesity prevention, screening, diagnosis, and treatment • Healthy living and active living at work • Weight gain and breastfeeding Business • Sugar-sweetened beverages community/private • Food and beverage options for children in restaurants sector • Nutritional standards for all food and beverages • Food and beverage retailing and distribution policies • Food and beverage marketing standards for children • Nutrition labeling system * There are a total of 20 recommended strategies. Strategies are duplicated in the table if more than one level or sector of action can support the implementation of the strategy. SOURCE: IOM, 2012a. a four-part television documentary series for a national audience (aired May 2012, but available for download or on CD without charge to communities for community screenings) and a set of activities for use by individual communities, including a series of bonus video shorts on specific topics related to obesity, a companion trade publication for a broad adult audience, three other documentaries for chil- dren and families (to be released May 2013), and a book and action guide geared to elementary school students and their teachers. The campaign is supported by a national-level information- and video-rich website4 and an extensive presence on social networks. Thus, TWOTN has both national (primarily the HBO series and associated website) and community components (e.g., community screenings, school ini- tiatives). Chapters 6 (national) and 8 (community) will address the potential evaluation of TWOTN in response to the Committee’s charge to identify “measurement ideas” to determine the reach, implementa- tion, outcomes, and impact of the overall campaign. Given the range of social media and advocacy efforts involved in TWOTN, it can serve as an illustrative example of some of the challenges and opportunities that are inherent in evaluation of similar obesity prevention initiatives. Box 1-2 provides background on the importance of the evaluation of TWOTN and other large-scale programs or campaigns. Obesity-Related Research Priorities Once established, obesity is difficult to reverse, and obese children are much more likely to become obese adults (American Dietetic Association, 2006; Bao et al., 1995; Bouchard, 1997; Freedman et al., 1999; Serdula et al., 1993; Thompson et al., 2007). Childhood obesity and weight gain may be associated with higher mortality and morbidity in adulthood, including cardiovascular disease, cancer, diabetes, sleep apnea, gout, and orthopedic problems (IOM, 2012a). Obese children also face social problems, such as 4  See http://theweightofthenation.hbo.com (accessed November 11, 2013). 24 Evaluating Obesity Prevention Efforts

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BOX 1-2 Importance of Evaluating The Weight of the Nation and Other Large- Scale Social Media and Advocacy Efforts The Weight of the Nation (TWOTN) is an example of one of many initiatives that have been undertaken to raise awareness and promote the rationale behind and recommendations of the Accelerating Progress in Obesity Prevention report (IOM, 2012a). Evaluation is one way to determine the effects TWOTN has on awareness of obesity and other outcomes, whether these effects were related to how the information was presented (e.g., through the television broadcast, website, or community events), and what potential actions were taken as a result. Evaluation results can then be used to guide future dissemination efforts for TWOTN, as well as for similar programs/campaigns. Careful formative evaluation increases the chances of success of programs/campaigns (Worden et al., 1988). Unfortunately too few studies have investigated uses of mass media for changing social networks, commu- nities, and places to fully understand how effective they can be (Abroms and Maibach, 2008). How effective are small-scale community programs/campaigns? Unfortunately most small-scale, community, mass media programs alone have not been effective (Noar, 2006; Snyder and Hamilton, 2002). One exception is long-term campaigns designed to increase advocacy for community policy changes that are framed on the themes of children’s health and social justice (Freudenberg et al., 2009). Most community-level campaign effects are small in size; Snyder and Hamilton’s (2002) meta-analysis of 48 mass media health campaigns found an average effect size (mean of correlations, Mr) of only 0.09. Moreover, the average effect size for purely persuasive campaigns were about half (Mr=0.05), whereas the average effect size for campaigns that promoted behaviors that were enforceable by law (e.g., seat-belt use) were almost double (Mr=0.17). How effective are national programs/campaigns? It is clear that national programs that have clear objec- tives, are intensive and focused, and are long term can achieve greater effects than those that do not (e.g., the Legacy truth® campaign) (Farrelly et al., 2005, 2009). Furthermore, adding community activities can help to increase reach and effectiveness (e.g., the VERBTM campaign, see Bauman et al., 2008; Berkowitz et al., 2008; Huhman and Patnode, 2013; Huhman et al., 2010); but sustained resources and funding are necessary. How can TWOTN or similar programs be evaluated? First, the objectives of a program/campaign need to be very clear—concise, well understood, and widely communicated. An important component is the socio-­ ecological levels at which the effects are expected to occur, that is, on individuals (awareness, attitudes, or behavior), social networks (peer pressure or social support), or communities/institutions (community action/ advocacy or policy) (Maibach et al., 2007). Equally important, what kinds of changes are expected? Some or all of the following may be in play: increased awareness of health issues or their social determinants (Clarke et al., 2012), individual-level antecedents to behavior (e.g., knowledge, attitudes, perceptions, self-efficacy, or intentions) (Fishbein and Ajzen, 2009), improved behavior of individuals, changed peer pressures, or social support within social networks (Rogers, 2003; Valente and Saba, 2001), community action/advocacy toward policy development/change (Freudenberg et al., 2009), or changes in characteristics of places (Maibach et al., 2007). To design an appropriate evaluation, evaluators need to understand the socio-ecological levels and the nature of the expected effects of the program or campaign they will be evaluating. Evaluations also need to be planned well ahead of the campaign so that appropriate control or comparison sites/data can be identified and pretest data can be collected. See Chapter 6 for detailed suggestions and considerations for evaluating the national-level objectives, Chapter 8 for evaluating the community-level objectives of TWOTN, and Chapter 10 for a summary of the challenges and opportunities inherent in evaluation of similar obesity prevention initiatives. Introduction 25

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determine these patterns (Chriqui et al., 2011; Ottoson et al., 2009), as well as better understanding of how and how well surveillance data are being used (Ottoson and Wilson, 2003). Environmental surveillance relevant to obesity includes national, state, and small area (e.g., county, municipality, school district, zip code) measures of the physical environment that influence individuals’ and families’ decision making relative to their energy intake and energy expenditure. Environmental data may be obtained from geographic information systems (GIS) that depict land uses (e.g., parks, streets, bike paths, buildings), commercial or other data sources that contain information on the existence of spe- cific types of facilities and outlets (e.g., recreational facilities, fast food, farmers’ markets, and other food retail), or through audit-type evaluations that document characteristics of the physical, food, school, child care, worksite, and other related environments (Brownson et al., 2009; McKinnon et al., 2009). For these data to be useful for surveillance purposes, however, they need to be publicly available and consistently compiled over time (Lee et al., 2010). Environmental surveillance efforts exist to some extent nation- ally (e.g., at the census block group or zip code levels) but only for limited measures of land use. Many individual research and evaluation studies and individual communities have compiled data on the physi- cal environment, but few exist nationwide, statewide, or consistently across small geographic areas (e.g., counties, municipalities, school districts, zip codes, etc.). National and community obesity prevention– related evaluation studies would benefit from consistent compilation and tracking of environmental data across geographic areas and over time. Environmental sensors in new wireless communication technolo- gies hold promise for more data of this kind becoming publicly available (e.g., Bravo et al., 2012), which could be combined with GIS data to measure physical activity or obesogenic environments (Frank et al., 2012; Kerr et al., 2011). Evaluation The culmination of the series of assessment, surveillance, and monitoring strategies and systems just described leads to summative evaluation. Evaluation lies in using interventions selectively or collectively, together with summative evaluation designs for comparison (over time or between groups of organiza- tions, communities, or people exposed or not exposed to an intervention) and measures based on common indicators to associate the intervention(s) with the outputs, outcomes, or impacts. This report will use the term evaluation to encompass the collectivity of the assessment, monitoring, and surveillance methods or systems and the summative evaluation designs to relate interventions to their outputs, outcomes, and impacts. The overriding purpose of summative evaluation is to be able to attribute, with a known degree of certainty, whatever outputs, outcomes, or impacts (effects) are found to the interventions presumed to have caused them. Such attribution depends on controlling with experimental and statistical methods the competing explanations for the effects. The degree of certainty is the statistical notion of “significance,” that is, the probability that a given observed and measured effect could have been caused by chance. Summative evaluations require at a minimum some pairing of pretest and post-test measures of the desired effects, or another method to compare a population exposed to one not exposed to the interven- tion. The variations in experimental and quasi-experimental designs to control for threats to the validity of the cause-and-effect attribution are widely established in the literature and textbooks of experimental research and program evaluation (e.g., Campbell and Stanley, 1966; Shadish et al., 2002). 32 Evaluating Obesity Prevention Efforts

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Indicators of Progress As detailed in Chapter 3, an overriding factor in the Committee’s selection of indicators for evalu- ation (assessment, monitoring, surveillance, and summative evaluation) relates to balancing the tension between comprehensiveness and selectivity. The Committee favored the latter. The nine guiding principles for indicator selection include accuracy, comparability, feasibility, health disparities/equity, parsimony, priority setting, relevance, scalability, and sustainability (see Appendix C). The portfolio of indicators presented in Chapter 4 balances measures of structure (e.g., inputs, resources), process (e.g., actions), and outcomes (e.g., incidence and prevalence of obesity, changes in diet and activity behaviors). For all indica- tors, the Committee paid careful attention to end-user relevance, so that the measurement is not simply an academic exercise but rather a process to stimulate conversations among various stakeholders and to facilitate evidence-based action. In accordance with its task, the Committee selected of indicators that align with the APOP strategies and that focus on policy, behavioral, and environmental changes related to food and physical activity. As discussed in Chapter 4, sleep, endocrine disruptors, and other physi- ological functions may be important areas to measure to address broader population health and obesity p ­ revention–related issues that do not directly link to APOP report topics (Keith et al., 2006). Finally, dif- ferences between evaluation of interventions with children and evaluation of interventions with adults have been considered in the selection of indicators. Promoting Health Equity and Reducing Disparities Of particular concern to the Committee from the outset of its discussions was the growing recog- nition that evaluating progress for the nation as a whole, or even for regions of the United States, will need to pay special attention to the disparities that have accompanied the obesity epidemic. This central concern is driven in part by the commitment of the Healthy People 2020 disease prevention and health promotion objectives for the nation, which focus on the social determinants of health and the elimination of disparities in health a centerpiece (Koh et al., 2011b). The concern for reducing disparities/promoting health equity is also driven by the growing recognition that the nation’s progress on several other health promotion objectives has been impressive in the aggregate, but often at the expense of widening rather than narrowing the disparities between segments of the population that are grouped by income, educa- tion, and sometimes ethnicity or race. Chapter 5 more fully addresses these issues, together with issues of representativeness of the survey samples and the periodicity and oversampling of key population segments in the NHANES. Recently, the World Health Organization Commission on Social Determinants of Health (Solar and Irwin, 2010) postulated three mechanisms by which health inequities are produced: (1) differential expo- sure to intermediary factors (e.g., poor material circumstances such as inadequate housing, hazards, and harsh living conditions); (2) differential vulnerability to health-compromising conditions (e.g., through limited education, income, and associated lower socioeconomic position); and (3) differential conse­ quences (e.g., poor-quality services or no access to services). In Chapter 8, the Committee seeks to provide framing and support for summative evaluation of interventions and tracking of progress across popula- tions at greater risk of obesity. Introduction 33

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In accordance with Section 4302 of the Affordable Care Act (ACA),9 passed in 2010, the Department of Health and Human Services (HHS) has developed and adopted new data collection stan- dards for race, ethnicity, sex, primary language, and disability status. The data standards represent a new opportunity for HHS to collect and use demographic data uniformly to shape its programs and policies. ­ In April 2011, HHS unveiled its 2011 Action Plan to Reduce Racial and Ethnic Health Disparities (Disparities Action Plan) (Koh et al., 2011a). The Disparities Action Plan leveraged multiple provisions embedded within the ACA, which not only offer a wide array of opportunities to improve access to care and to eliminate disparities, but also strengthen the federal government infrastructure for data collection. Specifically, Section 4302 focuses on the standardization, collection, analysis, and reporting of health dis- parities data. In October 2011, the newly adopted HHS data standards for race, ethnicity, sex, primary language, and disability status began to be implemented in all new HHS-sponsored population health s ­ urveys (at the time of the next major revision to current surveys) (Dorsey and Graham, 2011). This provides an example of efforts to standardize data collection to improve comparability across evaluation efforts, across jurisdictions and organizations, and over time. Taking a Systems Science Approach to Evaluation The biology of obesity is complex, and so are the behavioral and environmental triggers that con- tribute to obesity. Numerous seemingly disparate factors interact in ways, known or unknown, to create a powerful set of dynamics that promote obesity. Any solution to obesity will need to account for this com- plex web of biological, behavioral, and environmental factors. Building on current evaluation methods, ­ this systems science approach requires that evaluation planners consider the properties of a complex s ­ ystem while evaluating obesity prevention efforts. Several of the principles of systems science identified in this report are linked with diffusion theory (Rogers, 2003) that posits the importance of opinion leaders within systems and the impact of complexity on adoption of a new innovation. The Committee’s recommendation of indicators to assess the APOP report strategies and the national and community obesity evaluation plans are guided by the properties of complex systems, and the consideration of community and population values for evaluation of health promotion interventions outlined in previous IOM reports (IOM, 2010a, 2012a,b). To establish a robust evaluation framework (see Figure 1-1), the Committee considers the application of a complex systems science approach to be a promising and much-needed means of ensuring ongoing insight and lessons that will continue to inform the field (see Chapter 9). Why is a focus on complex systems different from what previous models used to frame obesity pre- vention evaluation? The socio-ecological model has been well accepted and continues to provide impor- tant insights as a descriptive model. The Committee recognized, however, the need to emphasize, not only the structural layers of systems, but also the interactions and reciprocal causal relationships among the many elements of the system, properties that the socio-ecological model does not capture as well. Hence, the recommendation to enhance the use of systems science approaches in evaluating progress in obesity prevention extends the evaluation methods from “complicated” systems (e.g., socio-ecological model) to “complex” systems. 9  See http://www.gpo.gov/fdsys/pkg/CREC-2009-11-19/pdf/CREC-2009-11-19-pt1-PgS11607-3.pdf#page=127 (accessed November 11, 2013). 34 Evaluating Obesity Prevention Efforts

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Summary The solution to the obesity crisis depends on finding what is working to affect the causes of obe- sity. This will require evaluation, which will depend on developing agreement on the use of (a) common i ­ndicators in assessing the status of communities; (b) surveillance to track changes in the status of commu- nities, regions, and the nation; (c) monitoring of the policies, programs, and other interventions associated with changes; and (d) summative evaluation of the extent to which interventions and combinations of interventions result in changes in outcomes. These essential ingredients to tracking progress in the nation’s efforts to prevent and control obesity are detailed in the chapters that follow. This iterative process begins with an assessment of the needs of the users of evaluation products and development of a framework that places the ingredients and products in relation to each other in a cycle of cause-effect assessments. This process ends with examinations of the implications of evaluation, from the perspective of populations experiencing disparities in overweight and obesity and from the perspective of whole systems. Although it would be ideal to approach evaluation from a complex multilevel framework and to adopt the evalu- ation plans found in this report, the Committee acknowledges that in several situations funding or logistical constraints may preclude such a full approach. Nevertheless, acquiring scaling evaluation data through more feasible means, such as “practice-based evidence” methods or grassroots-driven evaluation, may provide valuable insights and inform programs on how innovations might diffuse through systems (Brownson et al., 2012; Rogers, 2003). overview of the report Adapting the framing presented in the 2010 IOM report Bridging the Evidence Gap in Obesity Prevention, this report suggests ways to answer three questions in evaluation: Why, What, and How (see Figure 1-2). The answers seek to make the assessment, monitoring, surveillance, or summative evalua- tion procedures undertaken in given settings productive of evidence that will be relevant and useful to the evaluation users (reviewed in Chapter 2) and help to establish an infrastructure for monitoring progress of obesity prevention efforts at national, state, and community levels. This report answers the following questions: • Why? Describing why the proposed methods, procedures, or indicators for assessment, monitor- ing, surveillance, and summative evaluation need to be considered sequentially; • What? Describing what has been or can be accomplished through assessment, monitoring, sur- veillance, and summative evaluation, including —— describing the prevalence/incidence and trends of obesity and its determinants; —— describing the prevalence/incidence and trends of obesity prevention activities; —— understanding the effectiveness of the delivery and implementation of obesity prevention interventions; and —— identifying what plans to implement and improvements to make given a particular user’s context; and • How? Describing how to implement the “what” in a concrete and actionable way. Introduction 35

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Assessment, Surveillance, Monitoring, and Evaluation WHY are the methods, procedures, or indicators important? HOW do we WHAT has been implement or can be evaluation in a accomplished concrete and through actionable way? evaluation? FIGURE 1-2  Questions that guide evaluation research efforts. Figure 1-2.eps The Committee recognizes that a myriad of responses can be offered to the why, what, and how. In developing this report, the Committee sought to build on the APOP report and to apply state-of-the-art principles in evaluation, stakeholder engagement, and systems science. The next two chapters provide background on and fundamental concepts of evaluation. Chapter 2 focuses on the main stakeholders’ preferences and needs for evaluation information, including those of policy makers, advocates for interventions, community coalitions, and program managers. Chapter 3 pres- ents the framework for realizing the Committee’s vision—the inputs, activities, outputs, outcomes, and impacts necessary to improve assessment, monitoring, surveillance, summative evaluation, and enhanced data use to reduce obesity and improve population health and health equity. Chapters 2 and 3 are particu- larly geared toward a better understanding of how the Committee’s recommendations contribute toward closing evidence-to-practice gaps to improve and inform obesity prevention efforts. In Chapter 4 the Committee identifies readily available indicators that can be used at the national, and sometimes at the state and community levels, to measure progress in obesity prevention. Chapter 5 focuses on tools and research methods for measuring progress that are appropriate for populations with health disparities that are closely linked with social, economic, and environmental disadvantage. Chapter 6 details a National Obesity Evaluation Plan with suggested adaptations for state and regional plans. Chapter 7 presents a plan for community health assessments and surveillance and Chapter 8 p ­ resents a plan for monitoring of implementation and summative evaluations of the effects of community- level interventions. Chapter 9 offers a systems perspective for evaluating progress in obesity prevention. Measurement ideas for the HBO/IOM TWOTN campaign can be found in Chapters 6 (its national 36 Evaluating Obesity Prevention Efforts

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