Tennessee Obesity Taskforce On The Move Presented by: Joan Randall, MPH Administrative Director, Vanderbilt Institute for Obesity and Metabolism Executive

Tennessee Obesity Taskforce On The Move Presented by: Joan Randall, MPH Administrative Director, Vanderbilt Institute for Obesity and Metabolism Executive Director, Tennessee Obesity Taskforce

In 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. 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.

Obesity 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.

Adverse 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 population X 31.7% obesity rate X $1,429 additional costs per obese person = $2.8 billion per/year

Implications of Childhood Obesity Longitudinal 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 CSH Percent Overweight/Obese 39.5%

Military Childhood 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.

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

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 Responsibility Humans 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.

Mission: to strengthen partnerships and enhance collaboration in order to reduce the burden of obesity in Tennessee using systematic, multidisciplinary, and evidence-based strategies.

2008 CDC Obesity Funded State Develop & 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.

Eat 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.

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

Building Connections We are connected nationally We are connected statewide We are connected locally

National Partners Centers for Disease Control & Prevention Alliance for a Healthier Generation Robert Wood Johnson Foundation Save the Children Campaign for Healthy Kids Lets Move The Food Trust The Rudd Center Center for Science in the Public Interest Convergence Partnership

Shape 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 Somerville Have a clear plan Engage leaders Transdisciplinary (multidisciplinary) Multiple systems interacting Community mapping, information gathering Listen and build relationships ACTION oriented Surround Sound

Lessons learned continued Pay 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 campaign Summer is a very dangerous time - unstructured Energy gap in kids is about 125 calories per day Add up opportunities for physical activity and decreased consumption Its not just about organized sports!

Physical Activity Guidelines The 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 Run Standard 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 50 th 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 hilly Cons: - Very, very hilly Start with small steps Two Rivers Disc Golf Course, Nashville

Built Environment and Transportation Action Team The 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

Walkable Neighborhoods Walkable 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.

Walkability Cities in Tennessee Walk 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.

Walk Score Description 90100 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.

Walkability Scores CityScore Brentwood16 Chattanooga38 Clarksville28 Franklin36 Gallatin40 Hendersonville28 Knoxville42 Lebanon37 Memphis41 Manchester45 Murfreesboro29 Nashville39 Smyrna35

* www.ceosforcities.org/work/walkingthewalk www.walkscore.com Walking the Walk: How Walkability Raises Housing Values in U.S. Cities CEOs 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 value

Quantifying the Cost of Physical Inactivity Nearly 80 % of obese adults have diabetes, high blood cholesterol levels, high blood pressure, coronary artery disease or other ailments. 43 % of people with safe places to walk within ten minutes of home meet recommended activity levels. Only 27 % of those without safe places to walk are active enough.

http://www.ecu.edu/picostcalc/ http://www.ecu.edu/picostcalc/costcalculator/coi.asp

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

Parks and Recreation Action Team Rationale: 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.

EVERY CHILD OUTDOORS COALITION was 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

Early Childcare Rationale: 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, breastfeeding Gold Sneaker Initiative

Schools Action Team Rationale: 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.

School-Based Policy Coordinated 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.

Sugar Sweetened Beverages Rationale: 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

Food Systems Action Team Rationale: 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 Policy Food 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

What 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 poverty Lack of access to affordable transportation

How 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 vehicle 11.5 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

Methodology Data 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 level 2007 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 level

Methodology Scoring Converted individual measures to z-scores so that all measured on the same scale Created 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.

Food Deserts are in red and orange

Food desert impact areas are in red and orange

Food Desert Impact Areas Middle Tennessee

Food Desert Impact Areas East Tennessee

Conclusions: 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 areas Differences 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.

If there are food deserts, are there also food swamps?

Target Area: Faith-Based Settings Rationale: 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

Rationale: 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 Team

Poll 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 Tennessee

Results of Poll (contd) Coordinated School Health 45% very important, 31% somewhat important Joint Use 69% strongly support, 17% somewhat Soda 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

How are we doing? Methodology Obtained Behavioral Risk Factor Surveillance System (BRFSS) data from the CDC Combined data from 1997 2010 Used weights provided by CDC to adjust prevalence rates to be representative of state populations Used standard definitions of Overweight BMI 25 Obese BMI 30 Extreme obesity 40 Computed prevalence rates for each state and rank ordered them to get state rankings Computed US average using 50 states plus District of Columbia

Overweight Prevalence: US to TN TN moved ahead of US average around 2000. Declined in TN last year.

Obesity Prevalence: US to TN While the obesity rate in US continued to increase, dropped in TN from 2009 to 2010.

Overweight Prevalence: Race 3 out 4 and 2 out of 3 is not good. But, larger decrease among African Americans.

Obesity Prevalence: Race There continues to be a large disparity in obesity rates in TN.

Overweight Prevalence: Rural/Metro Decline in overweight is in Metropolitan areas not rural areas of TN.

Obesity Prevalence: Rural/Metro Obesity prevalence increased in rural areas and decreased in Metro areas.

Overweight Rankings We moved from 2 nd highest to 4 th highest from 2009 to 2010.

Obese Rankings We moved from 3 rd highest to 8 th highest from 2009 to 2010.

Data 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:

It is close, so we should be careful about bragging too much!

Reversing the obesity epidemic is a shared responsibility. There is a role for everyone in discovering ways to create supportive environments.

Documents

Tennessee Obesity Taskforce On The Move Presented by: Joan Randall, MPH Administrative Director, Vanderbilt Institute for Obesity and Metabolism Executive