EVALUATING OBESITY
PREVENTION EFFORTS

A Plan for Measuring Progress

Committee on Evaluating Progress of Obesity Prevention Efforts

Food and Nutrition Board

Lawrence W. Green, Leslie Sim, Heather Breiner, Editors

INSTITUTE OF MEDICINE
              OF THE NATIONAL ACADEMIES

THE NATIONAL ACADEMIES PRESS

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EVALUATING OBESITY PREVENTION EFFORTS A Plan for Measuring Progress Committee on Evaluating Progress of Obesity Prevention Efforts Food and Nutrition Board Lawrence W. Green, Leslie Sim, Heather Breiner, Editors

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THE NATIONAL ACADEMIES PRESS  500 Fifth Street, NW  Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. This study was supported by a grant between the National Academy of Sciences and the Michael & Susan Dell Foundation. Any opinions, findings, conclusions, or recommenda- tions expressed in this publication are those of the author(s) and do not necessarily reflect the views of the organizations or agencies that provided support for the project. International Standard Book Number-13:  978-0-309-28527-8 International Standard Book Number-10:  0-309-28527-5 Additional copies of this report are available for sale from the National Academies Press, 500 Fifth Street, NW, Keck 360, Washington, DC 20001; (800) 624-6242 or (202) 334- 3313; http://www.nap.edu. For more information about the Institute of Medicine, visit the IOM home page at: www. iom.edu. Copyright 2013 by the National Academy of Sciences. All rights reserved. Printed in the United States of America The serpent has been a symbol of long life, healing, and knowledge among almost all cul- tures and religions since the beginning of recorded history. The serpent adopted as a logo- type by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin. Suggested citation: IOM (Institute of Medicine). 2013. Evaluating obesity prevention efforts: A plan for measuring progress. Washington, DC: The National Academies Press.

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

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

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COMMITTEE ON EVALUATING PROGRESS OF OBESITY PREVENTION EFFORTS LAWRENCE W. GREEN (Chair), Professor, Epidemiology and Biostatistics, School of Medicine, University of California, San Francisco CHRISTINA BETHELL, Professor, Pediatrics, School of Medicine, Oregon Health and Science Center, Child and Adolescent Health Measurement Initiative, Portland RONETTE R. BRIEFEL, Senior Fellow, Mathematica Policy Research, Washington, DC ROSS C. BROWNSON, Professor, Epidemiology, Brown School and School of Medicine, Washington University in St. Louis JAMIE F. CHRIQUI, Senior Research Scientist, Health Policy Center, Institute for Health Research and Policy, University of Illinois at Chicago STEPHEN FAWCETT, Professor, Applied Behavioral Science, Director, Work Group for Community Health and Development, University of Kansas, Lawrence BRIAN R. FLAY, Professor, Public Health, Co-Director, Promise Neighborhoods Research Consortium, Oregon State University, Corvallis DEANNA M. HOELSCHER, Director and Professor, Michael & Susan Dell Center for Healthy Living, The University of Texas School of Public Health, Austin Regional Campus, TX JAMES W. KRIEGER, Chief, Chronic Disease and Injury Prevention, Public Health–Seattle & King County, WA LAURA C. LEVITON, Senior Advisor for Evaluation, Robert Wood Johnson Foundation, Princeton, NJ K. M. VENKAT NARAYAN, Professor, Global Health and Epidemiology, The Rollins School of Public Health, Emory University, GA NICO P. PRONK, Vice President & Chief Science Officer, HealthPartners, Inc., Bloomington, MN LORRENE RITCHIE, Director of Research, Atkins Center for Weight and Health, University of California, Berkeley ELSIE TAVERAS, Chief, Division of General Pediatrics, Director, Pediatric Population Health Management, Massachusetts General Hospital and Associate Professor, Department of Pediatrics and Population Medicine, Harvard Medical School, Boston, MA Study Staff LESLIE J. SIM, Senior Program Officer LYNN PARKER, Scholar HEATHER BREINER, Associate Program Officer SARAH SIEGEL, Senior Project Assistant (from October 2012) ELENA OVAITT, Senior Project Assistant (until August 2012) SARAH SLIWA, Mirzayan Policy Fellow (September to November 2012) FAYE HILLMAN, Financial Associate ANTON L. BANDY, Senior Financial Officer GERALDINE KENNEDO, Administrative Assistant LINDA D. MEYERS, Director, Food and Nutrition Board (until May 2013) CLYDE J. BEHNEY, Acting Director, Food and Nutrition Board (from May 2013) v

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Reviewers T his report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to provide candid and critical com- ments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report: David B. Allison, University of Alabama at Birmingham Cheryl Aspy, University of Oklahoma Jay Bernhardt, University of Florida Don Bishop, Minnesota Department of Health Jon Blitstein, RTI International Jan L. Breslow, The Rockefeller University Kelly Evenson, University of North Carolina, Chapel Hill Mary Kay Fox, Mathematica Tracy Fox, Food, Nutrition, and Policy, Consultants Robert Hiatt, University of California, San Francisco Pam Schwartz, Kaiser Permanente Glorian Sorensen, Harvard University Adolfo Valadez, Aetna Karen Webb, University of California, Berkeley Jean Wiecha, RTI International Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations nor did they see the final draft of the report before its release. The review of this report was overseen by Eileen T. Kennedy, Tufts University, vii

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and Caswell A. Evans, University of Illinois at Chicago. Appointed by the Institute of Medicine; they were responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution. viii Reviewers

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Preface T he history of successful public health progress in confronting and controlling complex threats to popu- lation health has been marked most significantly by the ability and agreement to conduct assessments of the outbreak, conduct surveillance of the movement of the threat over time and between places and populations, and to conduct evaluations of efforts to interrupt or control those threats. Effective evalua- tions have depended on the development of consensus on the specific indicators and measures for compar- isons in time and space and between jurisdictions with their varied policies, programs, services, cultures, as well as distinct physical and social environments. This report attempts to offer a degree of consensus on these essential ingredients for successful monitoring and evaluation of progress on obesity in America. We wish to thank the Michael & Susan Dell Foundation for sponsoring this study. We begin by thanking in particular Aliya Hussaini for her encouragement. The Foundation’s support and vision for the role that evaluation must play in accelerating progress toward obesity prevention offered inspiration. Its full support for urging common use of specific indicators in such evaluation was significant. The Committee deeply appreciates the extensive contributions of Debra Haire-Joshu, Ph.D., Washington University in St. Louis, who was commissioned to provide practical recommendations on disparities, health equity, and obesity prevention to inform the decisions of the Committee. Also, the Committee benefited greatly from the invaluable and illuminating assistance on evaluating the effective- ness of community-wide obesity prevention initiatives and on common measures provided by Carol Cahill, M.L.S., Group Health Cooperative; Diana Charbonneau, M.I.T., Group Health Cooperative; Allen Cheadle, Ph.D., Group Health Cooperative; Elena Kuo, Ph.D., Group Health Cooperative; Suzanne Rauzon, M.P.H., University of California, Berkeley; and Lisa Schafer, M.P.H., Group Health Cooperative. The opportunity for discussion with the individuals who made presentations and attended the Committee’s public session (see Appendix I) was critical to the Committee’s work. We also gained expe- rience and insight from discussions with individuals from a variety of perspectives and sectors, includ- ing Philip Bors, Healthy Kids, Healthy Communities; Richard Conlin, Seattle City Council; Tracy Fox, Food, Nutrition, and Policy Consultants, LLC; Casey Korba, America’s Health Insurance Plans; Punam Ohri-Vachaspati, Arizona State University; Mary Ann Scheirer, Scheirer Consulting; Pam Schwartz, Kaiser Permanente; Nancy Sherwood, HealthPartners Institute for Education and Research; Sarah Strunk, Healthy Kids, Healthy Communities; and Michael Yedidia, Rutgers University. ix

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The Committee could not have done its work without the outstanding guidance and support pro- vided by the Institute of Medicine staff Leslie Sim, study director; Heather Breiner, associate program officer; and Lynn Parker, scholar. Sarah Siegel and Elena Ovaitt provided highly skilled logistical support. Linda Meyers’ guidance and counsel were invaluable throughout our deliberations. And last but not least, the report greatly benefited from the copyediting skills of Cori Vanchieri. Lawrence W. Green, Chair Committee on Evaluating Progress of Obesity Prevention Efforts x Preface

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Contents SUMMARY 1 1 Introduction 15 2 Improving the Usefulness of Obesity Evaluation Information to Potential Users 43 3 Framework for Evaluation 73 4 Indicators for the Evaluation Plans 95 5  Evaluating Progress in Promoting Health Equity: A Review of Methods and Tools for Measurement 115 6 National Obesity Evaluation Plan 133 7 Community Obesity Assessment and Surveillance 183 8 Monitoring and Summative Evaluation of Community Interventions 223 9 Systems and Evaluation: Placing a Systems Approach in Context 255 10 Taking Action: Recommendations for Evaluating Progress of Obesity Prevention Efforts 273 APPENDIXES A Acronyms 297 B Glossary 303 C Guiding Principles for Evaluation 309 D Table of Indicator Data Sources 321 E Disparities Tables 331 F National Plan Resources 401 G Community Health Assessment and Surveillance Resources 413 H Community Intervention Resources 421 I Panel Agenda 441 J Committee Biographies 443 xi

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