CREATING EQUAL
OPPORTUNITIES
FOR A
HEALTHY WEIGHT

WORKSHOP SUMMARY

Heather Breiner, Lynn Parker, and Steve Olson, Rapporteurs

Standing Committee on Childhood Obesity Prevention

Food and Nutrition Board

INSTITUTE OF MEDICINE
OF THE NATIONAL ACADEMIES

THE NATIONAL ACADEMIES PRESS

Washington, D.C.

www.nap.edu



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Heather Breiner, Lynn Parker, and Steve Olson, Rapporteurs Standing Committee on Childhood Obesity Prevention Food and Nutrition Board

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THE NATIONAL ACADEMIES PRESS 500 Fifth Street, NW Washington, DC 20001 NOTICE: The workshop that is the subject of this workshop summary 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. This activity was supported by Contract/Grant No. 69449 between the National Academy of Sciences and the Robert Wood Johnson Foundation. The views presented in this publication do not necessarily reflect the views of the organizations or agencies that provided support for the activity. International Standard Book Number-13: 978-0-309-29473-7 International Standard Book Number-10: 0-309-29473-8 Additional copies of this workshop summary 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 Cover credit: Design by Casey Weeks. The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin. Suggested citation: IOM (Institute of Medicine). 2013. Creating equal opportunities for a healthy weight: Workshop summary. Washington, DC: The National Academies Press.

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The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the 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 responsibil- ity for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encour- ages 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 policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of 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 engi- neering 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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PLANNING COMMITTEE ON CREATING EQUAL OPPORTUNITIES FOR A HEALTHY WEIGHT1 SHIRIKI KUMANYIKA (Chair), Associate Dean for Health Promotion and Disease Prevention, Professor of Epidemiology, Perelman School of Medicine, University of Pennsylvania CELESTE CLARK, Retired Senior Vice President of Global Public Policy and Public Affairs, Chief Sustainability Officer, Kellogg Company PATRICIA CRAWFORD, Director, Dr. Robert C. and Veronica Atkins Center for Weight and Health, and Adjunct Professor, School of Public Health, University of California, Berkeley CHRISTINA ECONOMOS, New Balance Chair in Childhood Nutrition and Associate Professor of Nutrition, Friedman School of Nutrition Science and Policy, Tufts University, and Director, ChildObesity180 JAMES SALLIS, Distinguished Professor of Family and Preventative Medicine, Chief Division of Behavioral Medicine, University of California, San Diego ELLEN WARTELLA, Al-Thani Professor of Communication, Professor of Psychology, and Professor of Human Development and Social Policy and Director of the Center on Median and Human Development, Northwestern University, Evanston, Illinois IOM Staff LYNN PARKER, Scholar HEATHER BREINER, Associate Program Officer SARAH SIEGEL, Senior Program Assistant SARAH ZIEGENHORN, Research Assistant FAYE HILLMAN, Financial Associate GERALDINE KENNEDO, Administrative Assistant CLYDE BEHNEY, Acting Director, Food and Nutrition Board 1 Institute of Medicine planning committees are solely responsible for organizing the workshop, identifying topics, and choosing speakers. The responsibility for the published workshop summary rests with the workshop rapporteurs and the institution. v

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Reviewers This workshop summary has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published workshop summary as sound as possible and to ensure that the workshop summary meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the process. We wish to thank the following individuals for their review of this workshop summary: David V. B. Britt, Sesame Workshop (Retired) Diedra Chester, U.S. Department of Agriculture Sandra Hassink, Nemours Obesity Initiative, A.I. Dupont Hospital for Children Arnell Hinkle, Community Adolescent Nutrition & Fitness Although the reviewers listed above have provided many constructive comments and suggestions, they did not see the final draft of the workshop summary before its release. The review of this workshop summary was overseen by Hugh H. Tilson, University of North Carolina at Chapel Hill. Appointed by the Institute of Medicine, he was responsible for making certain that an independent examination of this workshop summary was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this workshop summary rests entirely with the rapporteurs and the institution. vii

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Contents 1 INTRODUCTION AND THEMES OF THE WORKSHOP 1 Reducing Disparities, 3 Understanding Health Equity, 5 Frameworks for Analysis, 6 Organization of the Workshop and This Summary, 8 Themes of the Workshop, 9 2 BUILDING PHYSICAL AND SOCIAL ENVIRONMENTS FOR PHYSICAL ACTIVITY IN HIGH-RISK COMMUNITIES 15 Strategies for Integrating Physical Activity into Everyday Life, 16 Case Study: The City Project, Los Angeles, 19 Advancing Health Equity Through Public Parks and Recreation Services, 23 3 COMBATING DISPARITIES IN THE FOOD AND BEVERAGE ENVIRONMENTS OF ETHNIC MINORITY AND LOW-INCOME COMMUNITIES 27 Strategies for Changing Food and Beverage Environments, 28 Case Study: Obesity Prevention Initiatives in Philadelphia, 31 Policy Issues, 35 4 EQUITY-FOCUSED APPROACHES TO OBESITY PREVENTION IN WORKPLACES 39 The Potential of Employee Wellness Programs, 40 Case Study: Total Health at Kaiser Permanente, 42 Improving the Health of WIC Employees, 45 5 PATHWAYS TO OBESITY PREVENTION FOR ETHNIC MINORITY AND LOW-INCOME CHILDREN AND ADULTS IN PRIMARY CARE 49 Strategies for Health Care Providers and Insurers in Obesity Prevention, 50 Case Study: The Power-Up After-School Program to Prevent Obesity, 53 ix

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x CONTENTS Obesity Prevention at the Upper Cardozo Health Center, Washington, DC, 57 6 ADVERTISING, PROMOTION, AND EDUCATION: BRINGING HEALTH EQUITY TO THE MESSAGE ENVIRONMENT 61 Strategies for Changing the Message Environment, 62 Case Study: The Advertising Council, 64 Understanding the Four Ps, 67 7 UPGRADING FOOD AND PHYSICAL ACTIVITY OPTIONS BEFORE, DURING, AND AFTER SCHOOL IN LOW-INCOME NEIGHBORHOODS 71 Strategies for Making Schools a Focal Point for Obesity Prevention, 72 Case Study: Food Services in the Riverside Unified School District, 74 Out-of-School Time, 77 8 BRINGING THE PIECES TOGETHER 81 Simplicity and Complexity, 82 Kinds of Systems Models, 82 Links Among Strategies, 83 Coordinated Action, 84 REFERENCES 87 APPENDIXES A WORKSHOP AGENDA 97 B SPEAKER BIOGRAPHICAL SKETCHES 103 C WORKSHOP PARTICIPANTS 113 D STATEMENTS AT THE WORKSHOP 115 E ABBREVIATIONS AND ACRONYMS 121