Setting Up Camp: How Do We Improve Nutrition, Increase Physical Activity and Prevent and Control Obesity? William H. Dietz, MD, PhD Division of Nutrition,

Setting Up Camp: How Do We Improve Nutrition, Increase Physical Activity and

Prevent and Control Obesity?

Setting Up Camp: How Do We Improve Nutrition, Increase Physical Activity and

Prevent and Control Obesity?

William H. Dietz, MD, PhD

Division of Nutrition, Physical Activity, and Obesity

Centers for Disease Control and Prevention

William H. Dietz, MD, PhD

Division of Nutrition, Physical Activity, and Obesity

Centers for Disease Control and Prevention

DNPAO Functional ModelDNPAO Functional Model

Long-Range Planning

Research

Program Development and Technical

Assistance

Surveillance

Policy Analysis

Admin./ Clerical Services

Leadership, Management & Accountability

Training

Partnerships and External

Relations

Translation & Dissemination

Division of Nutrition, Physical Activity, and ObesityProposed October-2008

Division of Nutrition, Physical Activity, and ObesityProposed October-2008

Physical Activity and Health Branch

Mike Pratt (Acting)Lisa Kimbrough

• Research Team• Surveillance Team• Guidelines Development &

Recommendations Team

Nutrition Branch

Larry Grummer-StrawnPaulette Murphy

• Research & Surveillance Team

• Surveillance Systems Team• Guidelines Development &

Recommendations Team• International Unit (M/M)

Obesity Prevention & Control Branch

Bill Dietz (Acting)Tonya Ross)

• Research & Surveillance Team

• Guidelines Development and Recommendations Team

Associate Director for Science

Deb Galuska

Program Development & Evaluation Branch

Rosanne FarrisBecky Payne

• Program Advancement Team

• Program Development and Translation Team

• Evaluation Team

Associate Director for Translation and Dissemination

Jude McDivitt

Associate Director for Policy , Partnerships, and Communication

Vacant

Program Resource Management

Office of the DirectorBill Dietz

Laurie Johnson

Associate Director for Policy, Partnerships,

And CommunicationsVacant, GS-685-15

Policy and Partnerships TeamCasey Hannan, Team Leader (GS-685-14)

Primary Team Functions:•Coordination - legislative/policy issues•Long-range planning•Materials development: position papers, briefings, testimony, Q/A documents, etc.•Inquiry response (policymakers/partners)•FOIA•Controlled correspondence•Issues management•Partnership development

Communications TeamVacant, Team Leader (GS-1001-14)

Primary Team Functions:•Strategic communication plan•Coordination - communication activities•Audience research•Message/materials development•Web design/maintenance•Inquiry response (media/public)•Media relations•Media training & TA•Issues management

Office of Policy, Partnerships, and Communications

Overview of Efforts to Control ObesityOverview of Efforts to Control Obesity

Problem definitionStrategy development

- Targets- Strategies: policy and environmental change

Implementation- Multi-sectoral- Evaluation

Social movements

Problem definitionStrategy development

- Targets- Strategies: policy and environmental change

Implementation- Multi-sectoral- Evaluation

Social movements

0

5

10

15

20

25

30

Non-HispanicWhite

Non-HispanicBlack

MexicanAmerican

NHANES III1988-1994

NHANES2003-2006

Overweight Prevalence by Race/Ethnicity for Boys Aged 6 - 11 Years

Pre

vale

nce

(%

)

Source: Ogden CL et al.JAMA. 2008;299:2401-5; MMWR 1997; 46:199-202

0

5

10

15

20

25

Non-HispanicWhite

Non-HispanicBlack

MexicanAmerican

NHANES III1988-1994

NHANES2003-2006

Overweight Prevalence by Race/Ethnicity for Girls Aged 6 - 11 Years

Pre

vale

nce

(%

)

Source: Ogden CL et al. JAMA. 2008;299:2401-5; ;MMWR. 1997:46:199-202.

Changes in Obesity Prevalence by Race/ethnicity, Boys 2-19 Years

Changes in Obesity Prevalence by Race/ethnicity, Boys 2-19 Years

0

10

20

30

40

50

1999-2000 2001-2002 2003-2004 2005-2006

Per

cen

t

Non-Hispanic White Non-Hispanic Black Mexican American

0

10

20

30

40

50

1999-2000 2001-2002 2003-2004 2005-2006

Per

cen

t

Non-Hispanic White Non-Hispanic Black Mexican American

Ogden CL et al. JAMA 2008;299:2401

Annual Adult per Capita Cigarette Consumption and Major Smoking and Health Events – US 1900-1998

Annual Adult per Capita Cigarette Consumption and Major Smoking and Health Events – US 1900-1998

YearYear

Thousands per yearThousands per year

19001900 19101910 19201920 19301930 19401940 19501950 19601960 19701970 19801980 19901990

Great DepressionGreat Depression

End of WW IIEnd of WW II

1st Surgeon General’s report

1st Surgeon General’s report

Broadcast advertising banBroadcast advertising ban

Federal cigarettetax doubles

Federal cigarettetax doubles

Fairness Doctrinemessages on TV and radio

Fairness Doctrinemessages on TV and radio

Nonsmoker’s rightsmovement begins

Nonsmoker’s rightsmovement begins

1st smoking cancer concern1st smoking

cancer concern Surgeon General’s report onenvironmentalTobacco smoke

Surgeon General’s report onenvironmentalTobacco smoke

Master settlement agreement

Master settlement agreement

Nicotine medications Available over the counter

Nicotine medications Available over the counter

1st World Conferenceon smoking and health1st World Conference

on smoking and health

19981998

1st Great American smokeout1st Great American smokeout

Average Daily Energy Gap (kcal/day)Average Daily Energy Gap (kcal/day)

Excess Weight Gained

(Lb)Daily Energy Gap

(kcal/day)

All Teens 10 110 -165

Overweight Teens 58 678 -1,017

Behavioral implications of 150 kcal:Replacing 1 can of soda (12 oz) with water (140 kcal)Reducing TV watching by an hour (167 kcal/day)1

Walking 1.9 hours instead of sitting (for a 30-kg boy) Increasing PE from 1 to 3 times/week (240 kcal)

Wang YC et al. Pediatrics 2006;118:e1721Wiecha et al. 2006; Arch Pediatr Adolesc Med 160:436

Principal TargetsPrincipal Targets

Reduce energy intake

Decrease high and increase low ED foods

Increase fruit and vegetable intake

Reduce sugar-sweetened beverages

Decrease television time

Breastfeeding

Increase energy expenditure

Increase daily physical activity






Breastfeeding



PolicyPolicy

Laws, regulations, formal and informal rules that are adopted on a collective basis to guide individual and collective behavior

Laws, regulations, formal and informal rules that are adopted on a collective basis to guide individual and collective behavior

Strategies to Increase Fruit and Vegetable Consumption

Strategies to Increase Fruit and Vegetable Consumption

Access – supermarketsSchool and community gardensCompetitive pricingPackagingStealth interventions (Garden Market)

Access – supermarketsSchool and community gardensCompetitive pricingPackagingStealth interventions (Garden Market)

Agreement between the Alliance for a Healthier Generation and the Soft Drink

Companies

Agreement between the Alliance for a Healthier Generation and the Soft Drink

CompaniesElementary schools

H2O8 oz juice without added sweeteners FF and LF regular and flavored milk

Middle schoolsSame standards, 10 oz portions

High schoolsNo and low kcal drinks, light juices, sports drinks

50% must be H2O and no or low Kcal; 100Kcal/container

Elementary schools

H2O8 oz juice without added sweeteners FF and LF regular and flavored milk

Middle schoolsSame standards, 10 oz portions

High schoolsNo and low kcal drinks, light juices, sports drinks

50% must be H2O and no or low Kcal; 100Kcal/container

NYCDHMH, Amend Article 47, NYC Health Code; Applies to Group Day Care in NYCNYCDHMH, Amend Article 47, NYC Health Code; Applies to Group Day Care in NYC

Television, video and other visual viewing– Cannot be used for children <2 yo– Limited 60 minutes per day of educational programs

or programs that actively engage child movement for children 2+ yo

60’ physical activity requiredEliminate sugar-sweetened beveragesProvide 1% or no-fat milk

Television, video and other visual viewing– Cannot be used for children <2 yo– Limited 60 minutes per day of educational programs

or programs that actively engage child movement for children 2+ yo

60’ physical activity requiredEliminate sugar-sweetened beveragesProvide 1% or no-fat milk

Principal TargetsPrincipal Targets






Breastfeeding








Breastfeeding



Strategies to Increase Rates of BreastfeedingStrategies to Increase Rates of Breastfeeding

Maternity care practices Prenatal counselingBaby-friendly hospitals

Workplace support for breastfeedingPeer support – peer counseling Professional support and educationPublic acceptance

Maternity care practices Prenatal counselingBaby-friendly hospitals

Workplace support for breastfeedingPeer support – peer counseling Professional support and educationPublic acceptance

www.cdc.gov/breastfeeding

Role of Physical Activity in Weight ControlRole of Physical Activity in Weight Control

• Dose to prevent obesity unknown• Dose to maintain weight after loss ~ 1 hr/d• Relatively modest impact on weight loss• Reduces obesity associated comorbidities

• Dose to prevent obesity unknown• Dose to maintain weight after loss ~ 1 hr/d• Relatively modest impact on weight loss• Reduces obesity associated comorbidities

• Informational– Community-wide education– Point of decision prompts

• Behavioral and social– School-based PE– Non-family social support– Individually adapted behavior

change• Environmental and policy

– Enhanced access with outreach– Urban design and land use

• Informational– Community-wide education– Point of decision prompts

• Behavioral and social– School-based PE– Non-family social support– Individually adapted behavior

change• Environmental and policy

– Enhanced access with outreach– Urban design and land use

Effective Interventions to Promote Physical Activity

Effective Interventions to Promote Physical Activity

The RE-AIM FrameworkThe RE-AIM Framework

R ReachE EffectivenessA AdoptionI ImplementationM Maintenance

Glasgow RE et al. Ann Behav Med 2004;27:3-12

R ReachE EffectivenessA AdoptionI ImplementationM Maintenance

Glasgow RE et al. Ann Behav Med 2004;27:3-12

“To obtain more evidence-based practice we need more practice-based evidence”

Green L, Ottoson JM. In Hiss et al, From Clinical Trials to Community: the Science of Translating Diabetes and Obesity Research, NIH, 2004.

Settings for the Prevention and Treatment of Obesity


• Medical Settings• School• Work Site• Community


Environment

Family

School

Worksite

Community

Chronic Care Model

Medical System

Information Systems

Decision Support

Delivery System Design

Self Management Support

Family/PatientSelf-Management

Dietz WH et al. Health Affairs 2007;26:430

Pediatric InitiativesPediatric Initiatives

Expert committee recommendations

Maine and Massachusetts collaboratives

NICHQ Network (NICHQ.org)

NCQA – HEDIS measures

AAP priority – Jeanne Lindros

Expert committee recommendations

Maine and Massachusetts collaboratives

NICHQ Network (NICHQ.org)

NCQA – HEDIS measures

AAP priority – Jeanne Lindros

Environment

Family

School

Worksite

Community

Chronic Care Model

Medical System

Information Systems

Decision Support

Delivery System Design

Self Management Support

Family/PatientSelf-Management

Dietz WH et al. Health Affairs 2007;26:430





Priority Physical Activity and Nutrition Actions for Schools

Priority Physical Activity and Nutrition Actions for Schools

• Coordinated school health program and school health council

• Assessment and planning (School Health Index)

• Quality health education• Staff wellness programs

• Coordinated school health program and school health council

• Assessment and planning (School Health Index)

• Quality health education• Staff wellness programs

• Additional opportunities for physical activity (e.g., recess, after school, walk to school)

• Quality PE• Healthy school nutrition

environment

• Additional opportunities for physical activity (e.g., recess, after school, walk to school)

• Quality PE• Healthy school nutrition

environment

% of Schools in Which Students Could Purchase Selected Food and Beverages From Vending

Machines, School Store, Canteen, or Snack Bar, 2000 and 2006

% of Schools in Which Students Could Purchase Selected Food and Beverages From Vending

Machines, School Store, Canteen, or Snack Bar, 2000 and 2006

3038

21

38

27

46

11

26

14

25

0

20

40

60

80

100

Bottled water Baked goodsthat are not low

in fat

Ice cream orfrozen yogurt

that is not low infat

Salty snacksthat are not low

in fat

2% or whole milk

Perc

en

t

2000 2006

3038

21

38

27

46

11

26

14

25

0

20

40

60

80

100

Bottled water Baked goodsthat are not low

in fat

Ice cream orfrozen yogurt

that is not low infat

Salty snacksthat are not low

in fat

2% or whole milk

Perc

en

t

2000 2006





Model Worksite InterventionsModel Worksite Interventions

DNPAO StairwellsSprint campusKP farmers’ markets and commissary

policyNYC purchasing policy

DNPAO StairwellsSprint campusKP farmers’ markets and commissary

policyNYC purchasing policy





The Somerville, MA InterventionThe Somerville, MA Intervention

Increased low ED foodsDiscouraged high fat and sugar foodsSchool wellness policyEnhanced school food serviceHealthy meeting and event policyExpanded pedestrian safety policiesWalk to school campaignCity employee fitness benefitLocal physician training

Increased low ED foodsDiscouraged high fat and sugar foodsSchool wellness policyEnhanced school food serviceHealthy meeting and event policyExpanded pedestrian safety policiesWalk to school campaignCity employee fitness benefitLocal physician training

Economos et al. Obesity 2007;15:1325

Needs Identified at the CDC’s Community Meeting

Needs Identified at the CDC’s Community Meeting

Development of a national strategic planClearinghouse for obesity prevention and

control programsEvidence-based and promising interventionsTraining in HEAL for policymakersStandardized evaluation toolsFlexible comprehensive funding

Development of a national strategic planClearinghouse for obesity prevention and

control programsEvidence-based and promising interventionsTraining in HEAL for policymakersStandardized evaluation toolsFlexible comprehensive funding

Largest Connected Subcomponent in Framingham Heart Study

Christakis and Fowler. NEJM 2007;357:370

A National Convergence Around Healthy Eating, Active Living

A National Convergence Around Healthy Eating, Active Living

DNPAO and State Programs

WK Kellogg Fndtn

California Endowment

RWJF

KP’s HEAL Initiative

Steps to aHealthier US

Elements Common to Social MovementsElements Common to Social Movements

Shared and personalized perception of a threatCommon frameGrass roots commitmentSocial network focused on collective actionLocal nodes with dense social ties, linked to

other groups with weak bridging ties (rapid diffusion of innovation)

Organizational structure

Shared and personalized perception of a threatCommon frameGrass roots commitmentSocial network focused on collective actionLocal nodes with dense social ties, linked to

other groups with weak bridging ties (rapid diffusion of innovation)

Organizational structure

Paul Revere’s Rideby

David Hackett Fischer

Documents

Setting Up Camp: How Do We Improve Nutrition, Increase Physical Activity and Prevent and Control Obesity? William H. Dietz, MD, PhD Division of Nutrition,