Shape Up SomervilleShape Up Somerville:A Community-Based Environmental Change A Community-Based Environmental Change

Obesity Prevention InterventionObesity Prevention Intervention

Christina Economos, Ph.D.Christina Economos, Ph.D.

New Balance Chair in Childhood NutritionNew Balance Chair in Childhood Nutrition

Friedman School of Nutrition Science and PolicyFriedman School of Nutrition Science and Policy

Tufts University, Boston MATufts University, Boston MA

R06/CCR121519-01 from the Centers for Disease Control and Prevention.

Additional support was provided by Blue Cross Blue Shield of Massachusetts, United Way of Mass Bay, The Potato Board, Stonyfield Farm, and Dole Foods.

BACKGROUND

• Proactive strategies required to prevent childhood obesity

• Individual behaviors must be addressed in the context of societal and environmental influences

• Most prevention studies target school environments

• Summer weight change recently shown to outpace expected gains with growth and development

• Community-based interventions that have a theoretical framework and are mutli-level and participatory in nature are needed to catalyze social change

The Society-Behavior-Biology Nexus as depicted in multidimensional space

Glass and McAtee Social Science & Medicine Volume 62, Issue 7, April 2006, Pages 1650-1671

Learn from other movements (tobacco, recycling, seat belts, breastfeeding)

Call for a Crisis Build on a sound scientific base Nurture spark plugs Recognize the importance of economics Develop coalitions and advocacy Use government strategically Employ mass communication

Create environmental and policy changes

Develop a clear plan

How do you spark social change?

Economos, C, Brownson, S, DeAngelis, M, Foerster, S, Tucker Foreman, C, Kumanyika, S, Pate R. What Lessons Have Been Learned From Other Attempts To Guide Social Change? Nutrition Reviews 2001; 59(3):40-56

• A community-based, participatory, environmental approach to prevent childhood obesity

• A 3 year controlled trial to study 1st – 3rd grade culturally and ethnically diverse children and their parents from 3 cities outside Boston

• Goals: – To examine the effectiveness of the model on the

prevention of undesirable weight gain in children

– Transform a community and inform social change at the national level

Shape Up Somerville: Eat Smart. Play Hard.

CBPR• Community-based participatory research

(CBPR) includes a collaborative partnership with the community in all phases of the research:– identifying the problem

– designing, implementing and evaluating the intervention

– building community capacity

– identifying how data informs actions to improve health within the community

Potential to influence cultural and social norms

Community Engagement Model

CommunityMapping:

Understanding connections

ParticipationAssessment:

Identifying partners

Information Gathering &

Delivery

Capacity Building:

Making it happen

Model Adapted from National Resources Canada

Employ The Social Change Model of Leadership Development

Hold community meetings

Community council formation

Perform environmental assessments

Logo and brand development

Conduct focus groups &key informant interviews

Listen…Build Relationships

&

Establish Trust

Identify the problem as a community priority

Capitalize on social injustices

Identify champions

Study Timeline

Planning and monitoring yearOct 02-Sept 03

Year 1Intervention

Oct 03-Sept 04

Year 2 Intervention

Oct 04-Sept 05

Baseline Pre School Year 1

MeasurementOct 03

Post School Year 1

Measurement

May 04 Pre School

Year 2Measurement

Sept 04

Post School Year 2

MeasurementMay 05

Summer

Baseline Overweight Prevalence

0

5

10

15

20

25

30

U.S. Intervention Control 1 Control 2

at risk

overweight

At risk: 85th to < 95th percentileOverweight: 95th percentileReference: CDC 2000Ogden JAMA 2006, Economos, 2003

INTERVENTION• Designed to increase energy expenditure (EE) of up

to 125 kcals per day beyond the increases in EE and energy intake that accompany growth

• Variety of increased opportunities for physical activity

• Availability of foods of lower energy density, emphasizing fruits, vegetables, whole grains, and low-fat dairy; foods high in fat and sugar were discouraged

• Multi-level approach:– Before, during, after school, home, community

Early MorningEnvironment

During School Environment

Afternoon Environment

At HomeSafe Routes to School Maps

Walking to School (-30 kcals)Healthier Home Breakfast

Fiber, Sugar, FatAppropriate Portion Sizes

Before School ProgramHealthier School Breakfast

Fiber, Sugar, FatAppropriate Portion SizesIncreased Fresh Fruits Breakfast Coordinator

Reinforcing Environments

Home Environment (~15 kcal)Parent Newsletter w/ couponsGrowth Reports Screen TimePromotional Gifts

Community EnvironmentCommunity “Champions”Restaurant ParticipationPediatrician Training & SupportCommunity TV AppearancesEthnic Group OutreachCommunity PA Resource GuideCommunity Events

At homeSafe Routes to School Maps Walking Home (-30 kcals)Healthy Home Snack Fiber, Sugar, Fat

After School ProgramCurriculum:

Cooking LessonsPhysical Activity (-30 kcals)Nutrition EducationProfessional Development

Classroom Micro UnitsPhysical Activity (- 25 kcals) 5 days/wk (10 min)Nutrition & Physical Activity Education 1 day/wk (30 min)

Healthier Fundraising Alternatives

Professional DevelopmentTeachersAdministratorsFood Service StaffPE Teachers

Physical Activity Equipment for Recess Physical Activity (- 25 kcals)

Healthier School LunchFiber, Sugar, Fat

Increased Fresh Fruits & VegetablesAppropriate Portion SizesImproved Presentation and AtmosphereSocial Marketing in CafeteriaAlternative “Healthier” A La Carte ItemsNew Food Service Equipment

(~25 kcals)

Home:Parent, Child, Family

Home:Parent, Child, Family

Home:Parent, Child, Family

School:Child, teachers, administration, staff

School:Child, teachers, administration, staff

School:Child, teachers, administration, staff

Community:After school programs

Community: Ethnic groups

Local Government

Health Care System

Community: RestaurantsMedia

Skills Development

Experiential Learning

Demonstrations

A La Carte Options: Before Shape Up….

After…Improved A La Carte Options

A La Carte Snack Sales Data• Sales fell from Sept. 2003 to Dec. 2003, making about $7,000 - $9,000/month less in revenues compared to 2002 data.

• Sales began to increasing in winter of 2004, showing increased student acceptance for new mix of products

• As of Oct. 2004 sales are now fairly even with sales prior to intervention

• Data is consistent with trends reported from other school systems.

Revenues per day by school year

600

800

1000

1200

1400

September October November December January February March

Months

Re

ve

nu

e

Revenue per Day School year 2002-2003 Revenue per Day School year 2003-2004

Revenue totals include Paid Lunches, Milk Purchases, and Teacher Sales in addition to A La Carte sales

HEAT Club: After School Program

Before school : Walking School Bus

Support from Community Champions

A year of consultation and guidance for being a visible role model

• Mayor Joe Curtatone• Aldermen • School Committee Members

Growing food, knowing food

School Gardens and Nutrition Education

Shape Up Somerville : Results• Engaged 90 teachers in 100% of 1-3 grade classrooms

(N=81)• Participated in or conducted 100 community events and 4

parent forums• Trained 50 medical professionals • Recruited 21 restaurants • Reached 811 families through 9 parent newsletters, and

353 community partners through 6 community newsletters  • Reached over 20,000 through a monthly media piece (11

months) • Recruited all 14 after-school programs • Developed community-wide policies to promote and

sustain change

Demographic Characteristics at Baseline  

Intervention Control 1 Control 2

N=342 N=485 N=207

Age (y) 7.90 ± 1.09 7.32 ± 0.93 7.82 ± 1.03

Grade (%)      

One 31.3% 48.0% 38.2%

Two 32.2% 24.7% 27.1%

Three 36.5% 27.2% 34.8%

Ethnicity (%)      

White 50.3% 37.5% 51.7%

Black 8.5% 25.6% 6.3%

Hispanic 19.0% 9.7% 23.7%

Asian 8.8% 2.3% 7.2%

Other 13.5% 24.9% 11.1%

Non-English Home Language (%)

33.6% 14.8% 34.3%

Variables Control 1 Control 2 Control 1 + 2

Intervention (Somerville vs.) -0.1307 -0.1048 -0.1005 (0.0203) (0.0235) (0.0011) Baseline BMI z-score -0.0328 -0.0448 -0.031 (0.3466) (0.2204) (0.1516) Sex 0.00003 -0.0058 -0.0022 (0.9963) (0.4323) (0.6475) Grade -0.0304 -0.0228 -0.0208 (0.3389) (0.5026) (0.3249) Age (in months) 0.0013 0.0011 0.0007 (0.5409) (0.6276) (0.6510) Ethnicity 0.0009 0.0052 0.0027 (0.0251) (0.5024) (0.3540) Primary language spoken at home 0.0079 0.0076 0.0129 (0.6279) (0.6837) (0.3255) Constant -0.0099 -0.0322 -0.0136 (0.8986) (0.6862) (0.8277)

Results of Change in BMI z-score PRE-POST Intervention (N = 1178),

Coefficients with p-values

Adjusted for all variables shown above plus the 30 participating schools

First Year Results

First Year Results

Limitations / Strengths• Controlled, but not randomized • Up-front investment both time and labor intensive • Dissemination and replication will require

community collaboration• Measured and followed a subset of the eligible

population

• Recruited and retained a large sample of ethnic and racially diverse, high-risk children from three communities

• One of the first community-based obesity prevention project to demonstrate prevention of weight gain

IMPLICATIONS

• Comprehensive strategies that involve changes in multiple environments reinforced with policies that ensure healthy living are a viable and necessary direction for the future

Nurture and follow the championsSome community members may need a little nudge to get them to initiate things on their own; others are already leading.

Build initial relationships through key informant interviews The process of asking community members for their opinions and input informs, empowers, and lays the foundation for trust.

School Administration buy-in is key If you want anything to happen on a school-wide level you need approval and support from the principals and

superintendent.

Global Lessons Learned: Build Support Networks

Keep the community informed of what you are doing. Build community support and recognition of the

project by informing community leaders who may not be involved in your specific work.

Engage people with family and community newsletters, letters to the editor, by publicizing events and by participating in discussions at town meetings and other committees.

Global Lessons Learned: Communications

Create mechanisms to hold people accountableEnvironments that have enforced policies, monthly meetings, and/or consistent monitoring are easier to work with.

When appropriate, ask programs and individuals to sign contracts, memorandums of commitment, or pledges.

Global Lessons Learned: Accountability

Provide professional development opportunities for those involved in your intervention i.e. teachers, food service directors, after school program leaders

Trainings allow for:

Reinforcement and transfer of knowledge

Relationship growth

Continued empowerment

Sense of personal investment

Program Sustainability

Global Lessons Learned: Professional Development

Say yes when you can in the communityPut your program agenda aside to build relationships and trust. Support other initiatives and issues in the community even if they have no direct link to your work.

During your planning year – LISTENBe realistic in your planning year: think about what you have heard, rather than what you want to achieve. There’s much to learn from others.

Global Lessons Learned: Community Relations

Provide stipends when you can.Respect the time of professionals by offering compensation. It will open doors and encourage collaboration.

Being present at events is key, not the materials you bring Go to as many community events as possible. Reach out to other providers and learn about other community issues.

Reach out to Community LeadersYou are surrounded by experts and sources of knowledge. Network with them.

Global Lessons Learned: Community Relations

Bring key stakeholders to the tableHaving the right people helps your project move ahead. Constantly

assess whether or not you have the key decision makers as part of your discussions. These players can change over time; be sure to know who does what in your community.

Parent engagement is easiest through personal connection Ask your partners to invite parents that they know to your events.

Global Lessons Learned:Don’t be Shy

Each community has different strengths and resources

Social change is slow and dependent on the health and strength of relationships

Focus on interventions that have:• Designated leadership• Designated meeting times for leadership• Sustainability potential

Global Lessons Learned: There is no MAGIC bullet

Replicating the intervention across the country through a RCT with 6 urban communities. RFA available at www.childreninbalance.org

Adapting and implementing the intervention through a RCT in 8 communities in rural America (CA, MS, KY, SC) with Save the Children

Distributing the HEAT Club after school curriculum through live and online trainings throughout the U.S. (>150 ASPs in 20 states) including an RCT

Tipping the Scales for HPHCF

Beyond Somerville

Tipping the Scales

• MA, ME, NH

• Key informant interviews – 75 to date

• Research and programmatic activities

• Wellness policies

• Legislation

• BMI data

Tipping the Scales

• Data analysis underway

• Preliminary observations – Awareness is high

– Interest in and efforts to control further growth of the problem are widespread and cross many sectors within the three states

– Appreciation for pressures schools face

– Impressive number of activities underway• Limited number include an evaluation component.     

• Differences of opinion about the role of growth monitoring

• Physician’s efforts encouraging

• Exciting efforts to develop resources to increase physical activity

www.childreninbalance.org