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Tennessee Obesity Taskforce On The Move

Presented by: Joan Randall, MPHAdministrative Director, Vanderbilt Institute for Obesity and Metabolism

Executive Director, Tennessee Obesity Taskforce

1In Public Health..We like to PREVENT diseases rather than treat them.Obesity is very difficult to treat, so Public Health has a major role in this arena.My focus is on policies, interventions and environmental strategies to prevent and control obesity.

Tobacco started with education, warnings on packages, taxes. Very long process, continued pressure from industry.2Obesity why be concerned?Excess weight and obesity often the result of physical inactivity and unhealthy eating have tremendous consequences on Tennessees health and economy.Both are linked to a number of chronic diseases (heart disease, stroke, diabetes, certain cancers, hypertension, osteoarthritis and asthma).Annual cost of obesity-related diseases in Tennessee estimated at $2.7 billion.

3Adverse Financial Consequences for Tennessee*An obese person has $1,429 per year more medical costs, or about 42 percent more costs, than someone of normal weight.*The total costs annually of obesity related diseases in Tennessee can be estimated as follows:6.3 million TN populationX 31.7% obesity rateX $1,429 additional costs per obese person= $2.8 billion per/year

Implications of Childhood ObesityLongitudinal studies demonstrate that childhood obesity is inextricably linked to health outcomes later in life.Rapid infant weight gain often leads to excessive weight gain by age 4.Overweight toddlers are 5 times as likely to be overweight adolescents.Overweight adolescents have a 70% risk of becoming overweight adults.60% of overweight children aged 5-10 already have one or more risk factors for heart disease and/or diabetes.

BMI 2008-2009 TN CSHPercent Overweight/Obese 39.5%

6MilitaryChildhood obesity has become so serious in this country that military leaders view it as a potential threat to our national security. Obesity the number 1 reason why applicants between the ages of 17 and 24 fail to qualify for military service.

Genes? Genes are important, but behavior and environment play a larger role in determining obesity outcomes.The percentage of obesity that can be attributed to genetics varies widely, depending on the population examined, from 6% to 85%. As of 2006, more than 41 sites on the human genome have been linked to the development of obesity.Regardless of the %, genes havent changed much over the last 40 yearsbut environment and behavior have.

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What separates the doers from the watchers?Some people have a natural propensity to exercise.Genes influence whether or not we exercise.Genes influence how our bodies respond to exercise.Genes influence adherence to exercise.We need to intensify efforts for certain individuals.

Molly Bray, University of Alabama Genes and Exercise Adherence

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If your spouse is obese, you have a 37% likelihood of being obese.If your sibling is obese, you have a 41% likelihood of being obese.If your friend is obese, the likelihood is 57%.Is It Contagious?Blend of Personal Responsibility and Collective ResponsibilityHumans have a very sophisticated regulatory system. However, we are highly responsive to environmental cues.Default conditions now contribute to obesity.Create conditions that are conducive to making healthier choices and support personal responsibility.

Notion that obesity is caused by irresponsibility and weakness govt intervention intrudes on personal freedomOur bodies try very hard to help us regulate our weighthowever.Default sitting to work, how get to work, school. Fast foodtake the stairs, parking place, movies = popcorn and soda, etc.11Mission: to strengthen partnerships and enhance collaboration in order to reduce the burden of obesity in Tennessee using systematic, multidisciplinary, and evidence-based strategies.

SOS 2007. Whats going on in Tennessee?122008 CDC Obesity Funded StateDevelop & maintain infrastructure for coordinated statewide nutrition, physical activity and obesity strategies;Convene and lead a process to develop and implement a state plan for nutrition, physical activity and obesity focus on policy and environment.

CDC funds 25 states (including Tennessee), 5-years to: 13Eat Well Play More addresses 6 target areas (mandated by CDC):1. Increased physical activity;2.Increased consumption of fruits and vegetables;3. Decreased consumption of sugar-sweetened beverages;4. Increased breastfeeding initiation and duration;5. Reduced consumption of high-energy dense foods;6. Decreased television viewing.

In all sectors: where we live, where we play, where we learn, where we heal, where we work, vulnerable pops14

Plan launched at Tennessee Public Health Association (TPHA) meeting in Cool Springs on September 17, 2010Plan has legs15

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All directions17Building ConnectionsWe are connected nationally

We are connected statewide

We are connected locallyNational PartnersCenters for Disease Control & PreventionAlliance for a Healthier GenerationRobert Wood Johnson FoundationSave the Children Campaign for Healthy KidsLets MoveThe Food TrustThe Rudd CenterCenter for Science in the Public InterestConvergence Partnership

Save the Children19Shape Up Somerville (2002-05)Dr. Christina Economos Tufts University, CDC Study

Shape Up Somerville: Eat Smart, Play Hard is a city-wide campaign to increase daily physical activity and healthy eating through programming, physical infrastructure improvements, and policy work. The campaign targets schools, city government, civic organizations, community groups, businesses, and other people who live, work, and play in Somerville. This effort began as a community-based participatory research study at Tufts University targeting 1st through 3rd graders in the Somerville Public Schools. Through this study, the Shape Up Somerville partners developed and implemented strategies designed to create energy balance for early-elementary school children.

Lessons Learned SomervilleHave a clear plan Engage leadersTransdisciplinary (multidisciplinary)Multiple systems interactingCommunity mapping, information gatheringListen and build relationshipsACTION orientedSurround SoundLessons learned continuedPay attention to stages of change (may need to use a stealth approach)Nurture the spark plugs in your community (champions high profile and within community)Media campaignSummer is a very dangerous time - unstructuredEnergy gap in kids is about 125 calories per dayAdd up opportunities for physical activity and decreased consumptionIts not just about organized sports!

Physical Activity GuidelinesThe U.S. Department of Health and Human Services (HHS) issues the Physical Activity Guidelines for Americans. Being physically active is one of the most important steps that Americans of all ages can take to improve their health. Adults should do at least 150 minutes (2.5 hours) a week of moderate-intensity, or 75 minutes (1 hour and 15 minutes) a week of vigorous-intensity aerobic physical activity, or an equivalent combination of moderate- and vigorous-intensity aerobic activity.

The Mile RunStandard for assessing students cardiovascular and respiratory fitness. During 2007-08 school year, none of the grade levels in Tennessee (2,4,6,8, HS), reached the national standard of the 50th percentile. They did not achieve the goal of running and/or walking a mile in the equivalent time it took their national peers.

Physical inactivity is predictive of health problems.

Pros: - Very, very hillyCons: - Very, very hilly

Start with small steps

Two Rivers Disc Golf Course, NashvilleIs it better for more people to get less exercise, or fewer people to get more exercise? Barfield Crescent Park in Murf26

Built Environment and Transportation Action TeamThe built environment includes all aspects of the environment that are modified by humans, including homes, schools, workplaces, parks and industrial areas, as well as transportation facilities such as roadways, greenways and sidewalks. Rationale: Research suggests that built environment affects rates of obesity by influencing physical activity patterns. Certain changes to the built environment can be made to enhance physical activity.

Built Environment and Transportation Policy: Safe Pathways to School bill - Increases penalty for speeding in marked school zone punishable by fine of no less than $100 and no more than $250. Designates $50 of such enhanced penalty to be used by TDOT for grants for safe pathways for students. (Did not pass in 2011, will re-file)Complete Streets ordinances in Nashville, Knoxville, Kingsport, Hendersonville

28Walkable NeighborhoodsWalkable neighborhoods offer surprising benefits to the environment, our health, our finances, and our communities.

The average resident of a walkable neighborhood weighs 7 pounds less than someone who lives in a sprawling neighborhood.Walkable neighborhoods have a center, whether it's a main street or a public space. People: Enough people for businesses to flourish and for public transit to run frequently. Mixed income, mixed use: Affordable housing located near businesses. Parks and public space: Plenty of public places to gather and play. Pedestrian design: Buildings are close to the street, parking lots are relegated to the back. Schools and workplaces: Close enough that most residents can walk from their homes. Complete streets: Streets designed for bicyclists, pedestrians, and transit.

29WalkabilityCities in TennesseeWalk Score is a number between 0 and 100 that measures the walkability of any address.http://www.walkscore.com/

The 42 largest cities in Tennessee have an average Walk Score of 34. The most walkable cities in Tennessee are Cookeville, Knoxville, and Memphis. The least walkable cities are Brentwood, Soddy-Daisy and La Vergne.

Walkable neighborhoods result from smart policy decisions that allocate our tax dollars and set the rules for development. The Walk Score algorithm looks at destinations in 13 categories and awards points for each destination that is between one-quarter mile and one mile of the subject residential property: grocery store restaurant coffee shop bar movie theater school park library bookstore fitness drug store hardware store clothing and music store30

Walk Score Description90100 Walker's Paradise Daily errands do not require a car. 7089 Very Walkable Most errands can be accomplished on foot. 5069 Somewhat Walkable Some amenities within walking distance. 2549 Car-Dependent A few amenities within walking distance. 024 Car-Dependent Almost all errands require a car.More time in the car means more money at the pump, less exercise, and more pollution. Communities: Studies show that for every 10 minutes a person spends in a daily car commute, time spent in community activities falls by 10%.3

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Walkability ScoresCityScoreBrentwood16Chattanooga38Clarksville28Franklin36Gallatin40Hendersonville28Knoxville42Lebanon37Memphis41Manchester45Murfreesboro29Nashville39Smyrna35

My address has a score of 18

32*www.ceosforcities.org/work/walkingthewalk www.walkscore.comWalking the Walk: How Walkability Raises Housing Values in U.S. CitiesCEOs for Cities report* Based on 94,000 transactions in 15 markets. Compared sale prices & WalkScores (1-100 based on number of nearby destinations . . .) Higher WalkScore correlated to higher home values.

Average to above average walkscore = $4,000 to $34,000 increase in home valueWalkability raises home values. The property value premium for walkability seems to be higher in more populous urban areas and those with extensive transit, suggesting that the value gains associated with walkability are greatest when people have real alternatives to living without an automobile. The nations urban leaders should pay close attention to walkability as a key measure of urban vitality and as impetus for public policy that will increase overall property values 33Quantifying the Cost of Physical InactivityNearly 80 % of obese adults have diabetes, highblood cholesterol levels, high blood pressure, coronaryartery disease or other ailments.

43 % of people with safe places to walkwithin ten minutes of home meet recommendedactivity levels. Only 27 % of thosewithout safe places to walk are active enough.The calculation uses an average of data from 76 million records from seven state studies conducted in the United States. The results are meant to provide an estimated cost of your physically inactive population to help you make better resource allocations. Since the scientific evidence base varies across the cost realms, a total estimate is provided as well as individual costs for medical care, workers compensation, and workers' lost productivity.34

http://www.ecu.edu/picostcalc/http://www.ecu.edu/picostcalc/costcalculator/coi.asp But one cost that is too rarely understood and factored into decisions at the state, city and organizational level is the mounting expense associated with a physically inactive population or workforce. A new tool helps leaders understand, estimate and address this cost. We have defined physical inactivity according to the Surgeon General as less than 30 minutes of moderate physical activity most, if not all, days of the week.35

http://www.ecu.edu/picostcalc/Transportation and Obesity

Sources: Centers for Disease Control National Health and Nutrition Examination Survey/ U.S. DOT Federal Highway Administration, Annual Vehicle Distance Traveled in Miles and Related Data

Conventional transportation policies and planning practices tend to favor the automobile.This is a chart Leslie put together. She had noticed a similar trend in the increase Vehicle Miles Traveled otherwise the amount per year that we drive, and the increase in obesity. The purple line is adult obesity since 1962 and the green is the VMT. This chart illustrates a correlation between transportation and personal health, and we believe that transportation projects should be held accountable for impacts on personal health, much like they are already held accountable for impacts on environment health such as air quality.

Countries with the highest levels of walking and cycling have much lower rates of obesity, diabetes, and hypertension than the United States.The Netherlands, Denmark, and Sweden, for example, have obesity rates only a third of the American rate. Public transit use is linked with higher levels of physical activity and lower rates of obesity. Transit users in the US average 19 minutes/day of walking as part of their journey using transit. As shown on this slide, obesity rates tend to be inversely related to rates of active transportation (walking and biking), suggesting that transport policy affects public fitness and health.40Parks and Recreation Action TeamRationale: Research shows a close correlation between public health and recreational opportunities.Active overweight and obese individuals have lower morbidity and mortality than normal weight individuals who are sedentary. Because disparities exist in physical activity among some at-risk populations, policies and environmental efforts need to be tailored to promote increased physical activity opportunities for these subgroups.

Different partnersIncidence of illness/deathIf you are a coach41

EVERY CHILD OUTDOORS COALITIONwas created to promote and support opportunities that encourage the children of Tennessee to engage with and experience the outdoors.

Rationale: The American Academy of Pediatrics strongly recommends breastfeeding as the preferred feeding for all infants. Research also shows that the longer an infant breastfeeds, the less likely he or she is to become overweight. Breastfeeding Bill Permits a mother to breastfeed her child in public, regardless of his or her age, rather than only if 12 months or youngers right to breastfeed in public. SB0083/HB0871 - Passed 32-0 in Senate, 94-0 in House on 4/4/11

Breastfeeding

In Tennessee, numbers are low.43

Early ChildcareRationale: Almost 1/3 of American children over 2 years of age are already overweight or obese, according to the National Health and Nutrition Examination Survey. For low income children, the numbers approach 39%. Healthy child development depends on eating nutritious food and being physically active every day. This is especially important during the preschool years when children are rapidly building their brains and bodies. DHS Rules and Regs regarding nutrition, screen time, breastfeedingGold Sneaker Initiative

Schools Action TeamRationale: Over 95 percent of young people are enrolled in schools; therefore, schools are powerful environments to shape the health of our children. According to the National Association of State Boards of Education (NASBE), Health and success in school are interrelated. Schools cannot achieve their primary mission of education if students and staff are not healthy and fit physically, mentally, and socially.Physical activity programs are linked to stronger academic achievement, increased concentration and improved math, reading and writing test scores. While childhood obesity rates increase, opportunities for students to be active have decreased. Students often consume up to 50% of their daily calories at school.

High school vending (adolescent 80%), fundraisers, school stores, walk and bike to school (greatest source of inadvertent activity is walking/biking to school)Partner with CSH45School-Based PolicyCoordinated School Health Governor Bill Haslam committed recurrent funding for CSH in budget.Physical Activity in schools: Requires local education agencies to include at least 30 minutes of physical activity each day, instead of 90 minutes each week, for elementary and secondary school students. Removed from consideration in 2011. PE fiscally prohibitive.

46 Sugar Sweetened BeveragesRationale: Studies show that the intake of sugared beverages (soda sweetened with sugar, corn syrup or other caloric sweeteners; and other drinks, such as sports and energy drinks) is associated with increased body weight, increased risk for diabetes, dental caries, poor nutrition and displacement of more healthful beverages. Sugar Sweetened Beverage Tax: Tax on bottled soft drinks containing caloric sweeteners. Imposes a one cent per fluid ounce privilege tax on sweetened soft drinks. Reduces from 5.5 percent to 4.5 percent the retail sales tax rate on food. (SB0521 Stewart/HB0537 Marerro). Placed behind the budget on 3/30/11

Breastfeeding, stairs, activity, food environment Baja Fresh47Food Systems Action TeamRationale: Research shows people in low-income or at-risk areas often have significantly less access to healthy foods than their middle class or affluent neighbors.This limited access to nutritious and affordable food contributes significantly to rising obesity rates and related health problems. Low-income areas have the highest rates of diabetes, hypertension and heart disease.

Food Access PolicyFood Desert Relief Act: Authorizes TN local development authority to issue revenue bonds and make proceeds available for loans to develop property for food desert relief (at interest rates lower than would otherwise be obtainable). (SB1176 Berke/HB1385 Fitzhugh) Buried behind the budget.Community Gardening: Allows local governments to establish community gardening programs. (SB0609/HB0906) Passed in Senate and House 2011

Role models, no TV in bedroom!Advertising49What is a Food Desert?An area with:Significant lack of access to fresh fruit and vegetables, low-fat milk, and other healthy choice products and items. Concentrated povertyLack of access to affordable transportation

50How do food deserts affect our communities?According to a recent USDA report:2.3 million or 2.2 percent of all households live more than a mile from a supermarket and do not have access to a vehicle11.5 million people, or 4.1 percent of people, who live below the poverty line in low-income areas are more than 1 mile from a supermarket

51 MethodologyData 2000 US Census data from the US Census Bureau which included Percent Black, Percent Hispanic, Single Mother Headed Households, Percent living in Poverty, and access to transportation at the census tract level2007 Economic Census which included Number of Grocery Stores, Number of Restaurants, and Number of Fast Food Restaurants measured as units per square mile at the zip code level 2008-2010 Behavioral Risk Factor Surveillance System (BRFSS) data to measure obesity, extreme obesity, diabetes, and hypertension at the county level 1999-2007 CDC Mortality data for nutrition related deaths at the county level52 MethodologyScoringConverted individual measures to z-scores so that all measured on the same scaleCreated food desert score as sum of z-scores for economic, demographic and food availability measures. Size is census tract. Averaged all zip codes that touch the census tract.Created a second food desert impact score by adding in the morbidity (BRFSS) and mortality data. Each census tract is in one and only one county.

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Food Deserts are in red and orange54

Food desert impact areas are in red and orange55

Food Desert Impact Areas Middle Tennessee56

Food Desert Impact Areas East Tennessee57Conclusions:Developed a methodology for combining spatial data starting with the smallest unit of resolution (census tract).Combine data sets to measure poverty, lack of transportation, availability of food resources, morbidity, and mortality.There is a large gap between scores in urban areas versus rural areasDifferences between scores are more pronounced when morbidity and mortality data is included.Food deserts occur in inner city urban areas and in most rural areas of Tennessee.Resources must be allocated to helping close the gap especially in rural areas in Tennessee.58

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If there are food deserts, are there also food swamps? 60Target Area: Faith-Based SettingsRationale: Faith-based leaders and institutions are in a powerful position to address healthier lifestyles. A large percentage of the population in Tennessee attends regular services at faith-based institutions, providing a forum for education, motivation and encouragement toward better health through faith-based avenues.

2 out of 3 Tennesseans self-identify as members of a religious group.Food, Faith and Health Summit April 30, 2012, Mt. Zion, Nashville

Bible Belt. Unfortunately, Tennessee is also labeled as part of the Stroke Belt, the Diabetes Belt, and the Kidney Stone Belt. 61Rationale: Given the amount of time adults spend at work, the worksite is an important environment where healthy behaviors can be influenced. Employers benefit from reduced health care costs, increased productivity and decreased absenteeism. Employees can benefit from improved health and morale. Worksite Wellness Conference 5/24/12 at Camp Widjiwagan (Nashville)

Worksite Wellness Action Team62Poll conducted March 17-22, 2011 (RBI Strategies, Denver, N=602 Registered Voters in TN)

As far as you know, how do childhood obesity rates in Tennessee compare with other states?45% worse than other states; 28% same; 6% better; 13% unsure

How concerned are you about obesity rates among children in Tennessee?48% very; 38% somewhat concerned; 9% not too concerned; 4% not at all concerned.

*12% increase in intensity (level of concern) from 2010

Polling: Voter Attitudes Toward Childhood Obesity in TennesseeResults of Poll (contd)Coordinated School Health 45% very important, 31% somewhat importantJoint Use 69% strongly support, 17% somewhatSoda Tax Would you favor or oppose raising taxes by one penny per ounce on sugar-sweetened beverages like non-diet Coca-Cola and Pepsi, sweat teas, and sports and energy drinks with all funds raised being directed to reduce the current sales tax rate paid on food purchases? 52% favored; 44% opposed

64How are we doing? MethodologyObtained Behavioral Risk Factor Surveillance System (BRFSS) data from the CDCCombined data from 1997 2010Used weights provided by CDC to adjust prevalence rates to be representative of state populationsUsed standard definitions of Overweight BMI 25Obese BMI 30Extreme obesity 40Computed prevalence rates for each state and rank ordered them to get state rankingsComputed US average using 50 states plus District of Columbia65Overweight Prevalence: US to TNTN moved ahead of US average around 2000. Declined in TN last year.66Obesity Prevalence: US to TNWhile the obesity rate in US continued to increase, dropped in TN from 2009 to 2010.67Overweight Prevalence: Race3 out 4 and 2 out of 3 is not good. But, larger decrease among African Americans.68Obesity Prevalence: RaceThere continues to be a large disparity in obesity rates in TN.69Overweight Prevalence: Rural/MetroDecline in overweight is in Metropolitan areas not rural areas of TN.70Obesity Prevalence: Rural/MetroObesity prevalence increased in rural areas and decreased in Metro areas.71Overweight RankingsWe moved from 2nd highest to 4th highest from 2009 to 2010.72Obese RankingsWe moved from 3rd highest to 8th highest from 2009 to 2010.73Data Conclusions:There is clearly some good news this year. We have seen declines in overweight, obesity, and extreme obesity overall.We see sharper declines among African Americans and in the major metropolitan areas of the state.Our national rankings have improved for overweight and obesity.There is much work to be done.We need to study these data more carefully to see which segments of the population are improving and which are not.We need to focus our efforts on the rural parts of the state.We need to continue to address our vulnerable populations.Thank the following states:741Mississippi34.47%2Alabama32.96%3WestVirginia32.86%4SouthCarolina31.99%5Kentucky31.80%6Louisiana31.72%7Texas31.70%8Tennessee31.66%9Michigan31.63%10Missouri31.35%It is close, so we should be careful about bragging too much!75

Reversing the obesity epidemic is a shared responsibility. There is a role for everyone in discovering ways to create supportive environments.76There is a role for everyone in discovering ways to create supportive environments to help individuals and families to easily make healthy food choices, enjoy a physically active lifestyle, and move toward a healthy weight. Invite questions and discussion.

Chart113.4196276714.551281155.5152723.210235830.913.9275031.315.4285632.917.1296335.115.5301434.316.92974

Adult Obesity %Childhood Obesity % (age 2-19)VMT in billion milesObesity/Vehicle Miles Traveled in U.S.

Sheet1123YearAdult ObesityChildhood ObesityVMT%% (age 2-19)in billion miles196213.4767197414.5512811980155.51527199423.2102358200030.913.92750200231.315.42856200432.917.12963200635.115.53014200834.316.92974

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Adult Obesity %Childhood Obesity % (age 2-19)VMT in billion milesObesity/Vehicle Miles Traveled in U.S.

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